Institutional-Specific Risk Stratification of Children With Congenital Heart Disease Undergoing Noncardiac Procedures. What are the Risks of Anesthesia at Your Institution?

Abstract

ONE OF the first publications to highlight the risks of general anesthesia was published in 1954. In this article, Beecher and Todd studied deaths associated with general anesthesia and surgery in 599,548 anesthetics performed at 10 institutions. They found the overall death rate due to anesthesia complications was 1 in 1,560.1Beecher HK Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive.Ann Surg. 1954; 140: 2-35Crossref PubMed Scopus (429) Google Scholar Several risk factors were identified, including using curare and administering anesthesia during the first and last decades of life. In the nearly 75 years since this important publication, anesthetic medications, techniques, and patient monitoring have made anesthesia delivery much safer. However, patient comorbidities and the complexity of procedural interventions have increased, as have societal expectations of healthcare. The Society of Thoracic Surgeons National Database was established in 1989 as a cardiothoracic surgical initiative to collect surgical outcome data at institutions across the United States.2The Society of Thoracic Surgeons. STSNational Database. Available at: http://www.sts.org/national-database. Accessed April 26, 2023.Google Scholar In 1994, the database was expanded to include children undergoing cardiac surgery for congenital heart disease (CHD), thereby creating the Society of Thoracic Surgeon's Congenital Heart Surgery Database (STSCHSD). It is now the largest database for patients with CHD, includes more than 120 programs in the United States, and documents 98% of congenital cardiac surgical procedures. In 2010, the Congenital Cardiac Anesthesia Society partnered with the STSCHSD to incorporate anesthesia-related elements into the database. This robust data set is generating publications to help inform and guide practice in the congenital cardiac surgical operating room. However, there remains a lack of data to guide anesthesia practice for CHD patients undergoing noncardiac surgery.3Mavroudis C Gevitz M Elliott MJ et al.Virtues of a worldwide congenital heart surgery database.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002; 5: 126-131Abstract Full Text PDF PubMed Scopus (11) Google Scholar, 4Jacobs JP Shahian DM D'Agostino RS et al.The Society of Thoracic Surgeons National Database 2017 Annual Report.Ann Thorac Surg. 2017; 104: 1774-1781Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 5Greene NH Jooste EH Thibault DP et al.A study of practice behavior for endotracheal intubation site for children with congenital heart disease undergoing surgery: Impact of endotracheal intubation site on perioperative outcomes-an analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database.Anesth Analg. 2019; 129: 1061-1068PubMed Google Scholar, 6Schwartz LI Twite M Gulack B et al.The perioperative use of dexmedetomidine in pediatric patients with congenital heart disease: An analysis from the Congenital Cardiac Anesthesia Society-Society of Thoracic Surgeons Congenital Heart Disease Database.Anesth Analg. 2016; 123: 715-721Crossref PubMed Scopus (36) Google Scholar, 7Vener DF Abbasi RK Brown M et al.The Congenital Cardiac Anesthesia Society-Society of Thoracic Surgeons Cardiac Anesthesia Database collaboration.World J Pediatr Congenit Heart Surg. 2020; 11: 14-21Crossref PubMed Scopus (6) Google Scholar Although big data set analyses may decrease variation in care at different institutions, it is important for each institution providing anesthesia for CHD patients to establish its own risk stratification and clinical care guidelines to improve anesthetic outcomes based on CHD severity and institutional resources.8Ing RJ Twite M Barrett C. Review of the Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on outcomes and quality implications for the anesthesiologist.J Cardiothorac Vasc Anesth. 2017; 31: 1934-1938Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Baijal et al. presented a new model to predict the occurrence of severe perioperative complications in patients with CHD undergoing noncardiac surgery and procedures.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar The purpose of this investigation was twofold. First, it assessed their internal stratification process for assigning a pediatric cardiac anesthesiologist or general pediatric anesthesiologist to the care of a patient with CHD for a noncardiac surgery or procedure. Second, it provided data about risk factors for perioperative complications within their institutional guidelines. The study retrospectively evaluated 1,005 children from birth to 19 years of age with a diagnosis of CHD who underwent a noncardiac surgery or procedure during a 2-year period. Cases performed in the cardiac catheterization laboratory or cardiac operating room were excluded from the study. Severe complications were defined as perioperative cardiopulmonary arrest or death within 30 days of the procedure.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar The incidences of perioperative cardiac arrest and perioperative death were both 1.6%. Using multivariate logistic regression analysis, the authors identified the following 5 predictors for severe complications: patient age younger than 3 years, an emergent surgery or procedure, a preoperative renal abnormality, preoperative mechanical ventilation, and a preoperative diagnosis of pericardial effusion. Interestingly, the study failed to find a significant impact of other markers of critical illness, such as preoperative oxygen saturation, pulmonary hypertension, arrhythmia, ventricular dysfunction, or pre-existing pulmonary or neurologic abnormalities. Other patient factors, including the number of ventricles, left or right systemic ventricle, and surgery type, were also not predictive of severe complications.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar The study also evaluated moderate complications, including an escalation in anticipated postoperative disposition or airway support, administration of intraoperative vasoactive medications, redo surgery within 30 days of the procedure, and unplanned readmission within 24 hours of the procedure. Five predictors for these complications were identified also: preterm birth, an American Society of Anesthesiologists Physical Status score of 4 and 5, major surgery, a preoperative respiratory abnormality, and severe pulmonary valve insufficiency. However, these risk factors were less able to predict the occurrence of moderate complications. The observed incidence of cardiac arrest and mortality of 1.6% by Baijal et al. was significantly lower than rates observed in previous studies.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar In 2000, Baum et al. found a 30-day mortality of 6.0% in patients with CHD undergoing noncardiac surgery; this rate was 3.5 times higher than that of patients without heart disease.10Baum VC Barton DM Gutgesell HP. Influence of congenital heart disease on mortality after noncardiac surgery in hospitalized children.Pediatrics. 2000; 105: 332-335Crossref PubMed Scopus (123) Google Scholar Similarly, Faraoni et al. observed an overall mortality of 2.8% in patients with CHD compared with 1.2% in patients without CHD in a propensity-matched review of the pediatric database of the American College of Surgeons National Surgical Quality Improvement Program.11Faraoni D Zurakowski D Vo D et al.Post-operative outcomes in children with and without congenital heart disease undergoing noncardiac surgery.J Am Coll Cardiol. 2016; 67: 793-801Crossref PubMed Scopus (71) Google Scholar The mortality rate associated with CHD patients undergoing noncardiac surgery is highest in neonates and infants less than a year of age, and then plateaus before increasing again in late adolescence and early adulthood.12Nasr VG Markham LW Clay M et al.Perioperative considerations for pediatric patients with congenital heart disease presenting for noncardiac procedures: A scientific statement from the American Heart Association.Circ Cardiovasc Qual Outcomes. 2023; 16e000113Crossref PubMed Scopus (1) Google Scholar One of the most striking findings of Baijal et al. was that children with single-ventricle physiology were not at higher risk for severe complications when compared with children with biventricular cardiac anatomy, as has been shown in prior investigations.13Ramamoorthy C Haberkern CM Bhananker SM et al.Anesthesia-related cardiac arrest in children with heart disease: Data from the Pediatric Perioperative Cardiac Arrest (POCA) registry.Anesth Analg. 2010; 110: 1376-1382Crossref PubMed Scopus (248) Google Scholar Similarly, pulmonary hypertension was not a significant predictor for moderate or severe complications despite the well-established risk of this condition in patients undergoing sedation or general anesthesia for cardiac and noncardiac procedures.14Carmosino MJ Friesen RH Doran A et al.Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization.Anesth Analg. 2007; 104: 521-527Crossref PubMed Scopus (191) Google Scholar The improved outcomes described in the current study by Baijal et al. may have reflected careful institutional patient selection for an anesthesia provider's level of training and experience and the use of clinical guidelines for the care of this patient population.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar,15Jortveit J Oyen N Leirgul E et al.Trends in mortality of congenital heart defects.Congenit Heart Dis. 2016; 11: 160-168Crossref PubMed Scopus (25) Google Scholar The current study highlights the importance of risk stratification and resource allocation for the care of children with CHD outside of the cardiac catheterization laboratory and cardiac operating room. Fifty-nine percent of patients were treated by general pediatric anesthesiologists, whereas 41% were treated by pediatric cardiac anesthesiologists.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar The relatively low rate of severe complications overall suggested that if individual institutional clinical selection criteria are followed, it is possible to accurately identify those patients at greater risk of an adverse anesthetic-related event. This idea was further supported by the fact that markers of critical illness frequently associated with increased risk for adverse events, including ventricular dysfunction, single ventricle CHD, pulmonary hypertension, or pre-existing pulmonary or neurologic abnormalities, were not predictive of complications in this study.9Baijal RGFH Sinton J Huang X et al.Perioperative risk assessment in children with congenital heart disease undergoing non-cardiac procedures [e-pub ahead of print].J Cardiothorac. 2023; (Accessed April 26)https://doi.org/10.1053/j.jvca.2023.03.034Abstract Full Text Full Text PDF Scopus (0) Google Scholar The authors rightly attributed this finding to their evidence-based guidelines that distinguished those patients who required the expertise of a pediatric cardiac anesthesiologist from those who could be treated safely for by a fellowship-trained pediatric anesthesiologist. However, it is possible that one institution's risk stratification process may not apply to another institution because of variations in clinical practice; these inherent differences are what large databases such as STSCHSD allow us to evaluate critically. Baijal et al. are to be commended for successfully developing and employing a risk stratification system in their institution and for identifying the factors that are most predictive of perioperative cardiac arrest and death. As the population of patients with CHD continues to increase, and more patients require anesthesia for noncardiac surgery and procedures, institutional risk stratification and patient selection are critically important to facilitate the safe perioperative care of this unique and heterogeneous patient population. None. Perioperative Risk Assessment in Children With Congenital Heart Disease Undergoing Noncardiac ProceduresJournal of Cardiothoracic and Vascular AnesthesiaPreviewTo risk-stratify children with congenital heart disease undergoing noncardiac surgery or diagnostic procedures for perioperative cardiopulmonary complications using the authors’ established institutional guidelines. Full-Text PDF