Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures

Abstract

To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes. A retrospective, cross-sectional study. A single-center quaternary-care freestanding children's hospital in the northeastern United States. Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018. Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging. Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p=0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p=0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p=0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p=0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001). Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.