Selected 2023 Highlights in Congenital Cardiac Anesthesia.

This article reviews the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist published in 2023. After a search of the US National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2023. The authors of this article considered the following topics noteworthy to be included in this review: (1) advancements in percutaneous mechanical support in children with congenital heart disease, (2) children with pulmonary hypertension undergoing surgery for congenital heart disease, (3) dexmedetomidine in pediatric cardiac surgery, and (4) recommendations for pediatric heart surgery in the United States: Implications for pediatric cardiac anesthesia.

Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial.

BACKGROUND: Acquisition of transthoracic echocardiographic (TTEcho) images in children often requires sedation. The optimal sedative for TTEcho has not been determined. Children with congenital heart disease are repeatedly exposed to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population. METHODS: A prospective, randomized, double-blind trial enrolled 280 children 3-24 months of age undergoing outpatient TTEcho, comparing 2.5 µg·kg intranasal dexmedetomidine to 5 mg·kg oral pentobarbital. Rescue sedation, for both groups, was intranasal dexmedetomidine 1 µg·kg. The primary outcome was adequate sedation within 30 minutes without rescue sedation, assessed by blinded personnel. Secondary outcomes included number of sonographer pauses, image quality in relation to motion artifacts, and parental satisfaction. RESULTS: Success rates with a single dose were not different between sedation techniques; 85% in the pentobarbital group and 84% in the dexmedetomidine group (P = .8697). Median onset of adequate sedation was marginally faster with pentobarbital (16.5 [interquartile range, 13-21] vs 18 [16-23] minutes for dexmedetomidine [P = .0095]). Time from drug administration to discharge was not different (P = .8238) at 70.5 (64-83) minutes with pentobarbital and 70 (63-82) minutes with dexmedetomidine. Ninety-five percent of sedation failures with pentobarbital and 100% of dexmedetomidine failures had successful rescue sedation with intranasal dexmedetomidine. CONCLUSIONS: Intranasal dexmedetomidine was comparable to oral pentobarbital sedation for TTEcho sedation in infants and did not increase the risk of clinically important adverse events. Intranasal dexmedetomidine appears to be an effective "rescue" sedative for both failed pentobarbital and dexmedetomidine sedation. Dexmedetomidine could be a safer option for repeated sedation in children, but further studies are needed to assess long-term consequence of repeated sedation in this high-risk population.

Interventions designed using quality improvement methods reduce the incidence of serious airway events and airway cardiac arrests during pediatric anesthesia.

BACKGROUND: Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement (QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests. METHODS: A quality improvement team consisting of members of the Department of Anesthesia was formed and QI data from previous years were analyzed. The QI team developed a Smart Aim, Key Driver Diagram, and specific Interventions that focused on the accessibility of emergency drugs, the use of nondepolarizing muscle relaxants for endotracheal intubation in children 2 years and younger, and the presence of anesthesia providers until emergence from anesthesia in high-risk patients. RESULTS: The percentage of cases where muscle relaxants were utilized in children 2 years and younger for endotracheal intubation and where atropine and succinylcholine were readily available increased at both our base and outpatient facilities. Over the 2.5-year study period, the incidence of serious airway events and airway cardiac arrests was reduced by 44% and 59%, respectively compared to the previous 2-year period. CONCLUSION: We utilized QI methodology to design and implement a project which led to greater standardization of clinical practice within a large pediatric anesthesia group. Based on an understanding of system issues impacting our clinical practice, we designed and tested interventions that led to a significant reduction in the incidence of serious airway events and airway cardiac arrests.

Perioperative Management of DORV.

The diagnosis of double-outlet right ventricle (DORV) characterizes a complex heterogeneous group of congenital cardiac malformations for which multiple classification schemes have been used. A clear understanding of the anatomy is critical to understanding the physiologic consequences of the specific type of DORV. Perioperative considerations include the medical management of the patient during the preoperative period, anesthetic and surgical management, and postoperative care. Both anesthetic and surgical management strategies are very different depending on the type of DORV. Key principles for anesthetic management include balancing the systemic and pulmonary circulations, optimizing systemic cardiac output, and closely monitoring for impaired oxygen delivery to the tissues. Depending on the specific anatomy the patient is usually placed on a 1- or 2-ventricle pathway, and initial palliation may involve placement of a systemic arterial to pulmonary artery shunt or pulmonary artery banding. In some cases the child may undergo a complete repair during the first few months of life. Surgical outcomes, both short and long-term, are dependent on the type of DORV and surgical procedure done. These patients require long-term follow up and may present for surgical or catheter-based interventions as adults.

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.

BACKGROUND: Ineffective communications among healthcare providers are common and increases the risk of medical errors. During the perioperative period, multiple handoffs occur within a short period of time, and failure to convey important patient information can compromise safety. We used quality improvement methodology to improve the reliability of our handoffs in the operating room and postanesthesia care unit (PACU). METHODS: Two quality improvement teams were developed to focus on the intraoperative and postanesthesia handoff processes. Key driver diagrams and 'smart aims' were developed for each process based on feedback from anesthesia and nursing staff, and handoff checklists were developed and revised using multiple plan-do-study-act cycles. Data on the reliability of the handoff processes were obtained prior to initiation of the projects and throughout the 6-month project period. RESULTS: The reliability of intraoperative anesthesia handoffs improved from 20% to 100% with use of the intraoperative handoff checklist. Similarly, with the introduction of a standardized PACU checklist, the reliability of PACU handoffs improved from 59% to greater than 90%. CONCLUSION: We utilized quality improvement methodology to develop and implement standardized checklists for handoffs of care in the operating room and PACU. Acceptance of and adherence to the standardized handoff protocols dramatically increased the quality and reliability of our handoff process.

A factorial study of ondansetron, metoclopramide, and dexamethasone for emesis prophylaxis after adenotonsillectomy in children.

BACKGROUND: We conducted a factorial study of emesis prophylaxis with ondansetron (OND), metoclopramide (MET), and dexamethasone (DEX). METHODS: After informed parental consent, 240 children having adenotonsillectomy were randomized to one of 15 combinations of OND (0-60 microg.kg(-1)), MET (0-400 microg.kg(-1)), and/or DEX (0-500 microg.kg(-1)). Using multivariable logistic regression, models were generated for the probability of emesis before discharge, after discharge and overall for 24 h. RESULTS: Odds of emesis increased by a factor of three to four for children older than 7 years. Before discharge, odds of emesis decreased by factors of 0.29 for each 15 microg.kg(-1) of OND and 0.37 for each 100 microg.kg(-1) of MET. After discharge, odds of emesis decreased by a factor of 0.67 for each 125 microg.kg(-1) of DEX and increased by a factor of 3.5 for emesis before discharge. Over 24 h, odds of emesis decreased with OND, MET, and DEX (ORs as above). A negative interaction between OND and MET was seen before discharge and over 24 h, reducing the efficacy of their combination. CONCLUSIONS: We present novel study design and methods of analysis which are uniquely suited to studies of multiple interventions. Factorial design was a powerful tool, allowing simultaneous determination of dose-response relationships for three drugs and identifying a previously unreported negative interaction between OND and MET.

Brain magnetic resonance imaging abnormalities after the Norwood procedure using regional cerebral perfusion.

OBJECTIVES: Neurologic deficits are common after the Norwood procedure for hypoplastic left heart syndrome. Because of the association of deep hypothermic circulatory arrest with adverse neurologic outcome, regional low-flow cerebral perfusion has been used to limit the period of intraoperative brain ischemia. To evaluate the impact of this technique on brain ischemia, we performed serial brain magnetic resonance imaging in a cohort of infants before and after the Norwood operation using regional cerebral perfusion. METHODS: Twenty-two term neonates with hypoplastic left heart syndrome were studied with brain magnetic resonance imaging before and at a median of 9.5 days after the Norwood operation. Results were compared with preoperative, intraoperative, and postoperative risk factors to identify predictors of neurologic injury. RESULTS: Preoperative magnetic resonance imaging (n = 22) demonstrated ischemic lesions in 23% of patients. Postoperative magnetic resonance imaging (n = 15) demonstrated new or worsened ischemic lesions in 73% of patients, with periventricular leukomalacia and focal ischemic lesions occurring most commonly. Prolonged low postoperative cerebral oximetry (<45% for >180 minutes) was associated with the development of new or worsened ischemia on postoperative magnetic resonance imaging (P = .029). CONCLUSIONS: Ischemic lesions occur commonly in neonates with hypoplastic left heart syndrome before surgery. Despite the adoption of regional cerebral perfusion, postoperative cerebral ischemic lesions are frequent, occurring in the majority of infants after the Norwood operation. Long-term follow-up is necessary to assess the functional impact of these lesions.

Brain magnetic resonance imaging abnormalities after the Norwood procedure using regional cerebral perfusion.

OBJECTIVES: Neurologic deficits are common after the Norwood procedure for hypoplastic left heart syndrome. Because of the association of deep hypothermic circulatory arrest with adverse neurologic outcome, regional low-flow cerebral perfusion has been used to limit the period of intraoperative brain ischemia. To evaluate the effect of this technique on brain ischemia, we performed serial brain magnetic resonance imaging in a cohort of infants before and after the Norwood operation using regional cerebral perfusion. METHODS: Twenty-two term neonates with hypoplastic left heart syndrome were studied with brain magnetic resonance imaging before and at a median of 9.5 days after the Norwood operation. Results were compared with preoperative, intraoperative, and postoperative risk factors to identify predictors of neurologic injury. RESULTS: Preoperative magnetic resonance imaging (n = 22) demonstrated ischemic lesions in 23% of patients. Postoperative magnetic resonance imaging (n = 15) demonstrated new or worsened ischemic lesions in 73% of patients, with periventricular leukomalacia and focal ischemic lesions occurring most commonly. Prolonged low postoperative cerebral oximetry (<45% for >180 minutes) was associated with the development of new or worsened ischemia on postoperative magnetic resonance imaging (P = .029). CONCLUSIONS: Ischemic lesions occur commonly in neonates with hypoplastic left heart syndrome before surgical intervention. Despite the adoption of regional cerebral perfusion, postoperative cerebral ischemic lesions are frequent, occurring in the majority of infants after the Norwood operation. Long-term follow-up is necessary to assess the functional effect of these lesions.