Pediatric Cardiac Anesthesia Research Articles

Anesthesia in adult patients with congenital heart disease

Recent advances in prenatal diagnosis, interventional cardiology, pediatric cardiac surgery, anesthesia, and critical care have resulted in an increasing number of adult patients with congenital heart disease (CHD). Most of these patients will require noncardiac surgery thus presenting a new challenge for anesthesiologists. The purpose of this article is to summarize preoperative and intraoperative implications for the anesthesiologist in the noncardiac surgery setting. These patients present with an increased risk of perioperative mortality. One of the most specific recommendations from the American College of Cardiology conference published in 2001 was that adult patients with moderate-to-severe CHD undergoing noncardiac surgery should be referred to an adult CHD center with the consultation of an expert anesthesiologist. However, though most experts agree that grown-up CHD poses an increasing risk for noncardiac surgery, no major study focusing on this topic has yet been performed. The number of adult patients with CHD is now superior to the number of children. This is a new challenge for anesthesiologist in the noncardiac surgery settings.

Anesthesia for major general surgery in neonates with complex cardiac defects

Centers with large cardiac workloads may be presented with neonates who need major general surgery before correction or palliation of a serious cardiac defect. This is still a rare situation with only three short case reports available in the medical literature (1-3). We have reviewed the anesthetic and analgesic regimens of 18 such neonates who presented to the Birmingham Children's Hospital in the 4-year period 2004-2007. These children require meticulous preoperative evaluation and although it might be anticipated that they would pose a serious challenge to anesthetists, in reality with thorough investigation, preparation, and careful management, they tolerate general anesthesia well. These children may be transferred to centers of specialist pediatric cardiac anesthesia to be benefited from experience obtained there.

Anaesthetic complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease

Congenital heart defects are the most common cause of death in infants and young children in the developed world. As the mortality in this population has declined to less than 5%, more attention is being focused now on reducing post-procedural morbidities that may seriously impact the patient and their families. Because of multiple reasons, paediatric cardiac surgery and anaesthesia is a perfect model for studying human errors and their impact on patient safety. Congenital cardiac disease is a common lesion causing much morbidity, pain, and loss of life. Over 44,000 surgical procedures are performed yearly to repair congenital cardiac problems in the United States alone. The reduction or elimination of iatrogenic adverse outcomes, given the current mortality rates of 4.2%-4.5%, might lead to as many as 500 children achieving better outcomes or shorter hospitalizations.Efforts to quantify the frequency of complications related to anaesthesia in patients undergoing congenital cardiac surgery have been difficult to date because of the low occurrence of this surgery compared to other surgeries on children and the relatively rare incidence of complications related to anaesthesia in this population. Anaesthesiologists play a crucial role in the reduction, recognition, and timely treatment of medical errors that impact this morbidity. Paediatric cardiac surgery encompasses many complex procedures that are highly dependent upon a sophisticated organizational structure, effective communication, coordinated efforts of multiple individuals working as a team, and high levels of cognitive and technical performance. Human factor error analysis in this patient population has shown how frequently both minor and major errors occur. The goal of this paper is to outline the frequency and sources of these errors and to suggest treatment strategies which may minimize their occurrence.

Gastric fundoplication is effective in promoting weight gain in children with severe congenital heart defects

The aim of this study was to determine outcomes, including weight gain, morbidity, and mortality, of children with severe congenital heart disease who underwent fundoplication (FP) for gastroesophageal reflux disease. An institutional review board-approved retrospective review was conducted on all children with congenital heart disease who underwent FP from 1999 to 2005. Preoperative age, weight, cardiac procedures, postoperative weight, and mortality were extracted from medical records. The Wilcoxon signed rank, Wilcoxon rank sum, and log-rank tests were used; P value less than .05 was significant. All procedures were performed with dedicated cardiac anesthesia personnel with recovery in a cardiac intensive care unit. Of 112 subjects identified, 37 (33%) had single ventricle (SV) physiology. The most frequent cardiac procedures performed were Norwood (33), pulmonary artery band (11), and systemic pulmonary artery shunt (11). A total of 104 laparoscopic FPs (with 2 conversions to open) and 8 open FPs were performed. The median preoperative age was 3 months, and weight percentile was 1.5%. From baseline, postoperative median weight percentiles increased to 4% at 3 months (P < .001) and to 20% at 5 years postoperatively (P = .004). Single ventricle physiology had no significant effect on outcomes. Postoperative mortality (< or =30 days) was 4.5% (5/112); 5-year survival was 74% (83/112). Five-year survival of SV subjects (59%) was significantly lower (P = .03) than that of the other subjects (81%). No significant difference in survival was seen between SV subjects with FP and all SV patients seen at our center during the study period. Only one death was directly related to antireflux surgery (SV subject). There were 8 patients who had recurrent gastroesophageal reflux disease: 4 were treated with reoperation, and 4 were treated medically. Weight gain in this high-risk population can be expected after antireflux surgery. Mortality is high because of intrinsic disease, especially in the SV population. Fundoplications performed with the assistance of dedicated pediatric cardiac anesthesia personnel followed by recovery in a cardiac intensive care unit is possible with acceptable postoperative morbidity and mortality.

The Basic of Pediatric Cardiac Anesthesia

The Basic of Pediatric Cardiac Anesthesia

Establishing Pediatric Cardiovascular Services in the Developing World

There is increasing realization that the lack of facilities for sustainable pediatric cardiac services in the developing world results in a massive number of preventable deaths and suffering. It is estimated that 15 million children die or are crippled annually by potentially treatable or preventable cardiac diseases. Ignored for a long time, this issue is starting to be a cause of major concern to individuals, governments, and, most importantly, cardiovascular specialists who can appreciate the gravity of the problem and that the current situation is unacceptable. What then can be done to alleviate the problem, by whom, and how? In this issue of Circulation , Larrazabal et al describe the pioneering efforts of Castenada and his colleagues in Guatemala.1 This should act as a model and a source of inspiration in this field. This editorial is an attempt to outline some of the issues that relate to the problem, such as estimates of its size, and explores potential, long-lasting solutions. Article p 1882 The pediatric population constitutes a larger proportion of the community in developing countries, with ≈40% of individuals <18 years old in some countries. Children in developing countries have a significantly higher incidence and prevalence of serious cardiac diseases.2 This is contributed to by a variety of factors that include a lack of early correction of congenital cardiac abnormalities that results in accumulation of a large number of children with uncorrected anomalies who survive the neonatal period. In addition, many of these children develop more rapid deterioration in their clinical condition as a result of accelerated forms of secondary changes in the heart and other organs, such as pulmonary hypertension. Some of these changes could be the result of genetic and/or environmental factors such as pollution or infection. Furthermore, endemic “neglected” cardiac diseases such as rheumatic …

Mentorship, learning curves, and balance

Professionals working in the arena of health care face a variety of challenges as their careers evolve and develop. In this review, we analyze the role of mentorship, learning curves, and balance in overcoming challenges that all such professionals are likely to encounter. These challenges can exist both in professional and personal life. As any professional involved in health care matures, complex professional skills must be mastered, and new professional skills must be acquired. These skills are both technical and judgmental. In most circumstances, these skills must be learned. In 2007, despite the continued need for obtaining new knowledge and learning new skills, the professional and public tolerance for a "learning curve" is much less than in previous decades. Mentorship is the key to success in these endeavours. The success of mentorship is two-sided, with responsibilities for both the mentor and the mentee. The benefits of this relationship must be bidirectional. It is the responsibility of both the student and the mentor to assure this bidirectional exchange of benefit. This relationship requires time, patience, dedication, and to some degree selflessness. This mentorship will ultimately be the best tool for mastering complex professional skills and maturing through various learning curves. Professional mentorship also requires that mentors identify and explicitly teach their mentees the relational skills and abilities inherent in learning the management of the triad of self, relationships with others, and professional responsibilities.Up to two decades ago, a learning curve was tolerated, and even expected, while professionals involved in healthcare developed the techniques that allowed for the treatment of previously untreatable diseases. Outcomes have now improved to the point that this type of learning curve is no longer acceptable to the public. Still, professionals must learn to perform and develop independence and confidence. The responsibility to meet this challenge without a painful learning curve belongs to both the younger professionals, who must progress through the learning curve, and the more mature professionals who must create an appropriate environment for learning. In addition to mentorship, the detailed tracking of outcomes is an essential tool for mastering any learning curve. It is crucial to utilize a detailed database to track outcomes, to learn, and to protect both yourself and your patients. It is our professional responsibility to engage in self-evaluation, in part employing voluntary sharing of data. For cardiac surgical subspecialties, the databases now existing for The European Association for CardioThoracic Surgery and The Society of Thoracic Surgeons represent the ideal tool for monitoring outcomes. Evolving initiatives in the fields of paediatric cardiology, paediatric critical care, and paediatric cardiac anaesthesia will play similar roles.A variety of professional and personal challenges must be met by all those working in health care. The acquisition of learned skills, and the use of special tools, will facilitate the process of conquering these challenges. Choosing appropriate role models and mentors can help progression through any learning curve in a controlled and protected fashion. Professional and personal satisfaction are both necessities. Finding the satisfactory balance between work and home life is difficult, but possible with the right tools, organization skills, and support system at work and at home. The concepts of mentorship, learning curves and balance cannot be underappreciated.

Beginning a career in pediatric cardiac anesthesia: up the creek, but where’s the paddle?

Pediatric AnesthesiaVolume 17, Issue 5 p. 407-409 Beginning a career in pediatric cardiac anesthesia: up the creek, but where’s the paddle? VICTOR C. BAUM MD, VICTOR C. BAUM MD Departments of Anesthesiology Pediatrics, University of Virginia Medical Center, Charlottesville, VA, USASearch for more papers by this authorDUNCAN G. DE SOUZA MD, DUNCAN G. DE SOUZA MD Departments of AnesthesiologySearch for more papers by this author VICTOR C. BAUM MD, VICTOR C. BAUM MD Departments of Anesthesiology Pediatrics, University of Virginia Medical Center, Charlottesville, VA, USASearch for more papers by this authorDUNCAN G. DE SOUZA MD, DUNCAN G. DE SOUZA MD Departments of AnesthesiologySearch for more papers by this author First published: 17 April 2007 https://doi.org/10.1111/j.1460-9592.2007.02212.xCitations: 1 Victor Baum, Department of Anesthesiology, Box 800710, University of Virginia Medical Center, Charlottesville, VA 22908-0710, USA (email: [email protected]). Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume17, Issue5May 2007Pages 407-409 RelatedInformation

Postal survey of training in pediatric cardiac anesthesia in the United Kingdom1

There are no nationally agreed standards for training in pediatric cardiac anesthesia despite the recommendation of two reports. Since then, anesthesia training has changed because of the introduction of competency-based training, the New Deal and the European Working Time Directive. We surveyed consultant pediatric cardiac anesthetists to establish what training they had undergone and to compare this with what they would recommend for training in the specialty. We also wanted to determine the profession's views on establishing training guidelines and what areas of practice to include when setting standards. Seventy-three percent of consultants want the Royal College of Anaesthetists to set standards for training. The majority had spent at least 2 years training in general pediatric, adult cardiac and pediatric cardiac anesthesia as well as pediatric intensive care and had spent time gaining experience overseas. They would recommend the same experience for others but this is unlikely to happen within the current constraints of specialist registrar training. Therefore, further training in a fellowship program in the UK or abroad is likely to be necessary.

Core Topics in Cardiac Anaesthesia

Core Topics in Cardiac Anaesthesia: J. M. Mackay, J. E. Arrowsmith (eds). Greenwich Medical Media Ltd.: London, 2004, 388 pp; indexed, illustrated, ISBN: 0521868416; Price £45.00 The editors have aimed this book at anaesthetic trainees in their first 3–6 months of training in cardiac anaesthesia and intensive care. This 367-page book consists of 66, three- to six-page, topics grouped into 11 sections. The sections are anatomy and physiology, cardiac pharmacology, diagnosis of cardiac disease, cardiac surgery for anaesthetists, monitoring, routine coronary heart surgery, anaesthetic management of specific disorders, paediatric cardiac anaesthesia, cardiopulmonary bypass, cardiac intensive care and miscellaneous topics. These have been chosen on the basis of guidelines from the Royal College of Anaesthetists, the Society of Cardiovascular Anesthesiologists and past exam papers.The editors have managed to maintain a consistent style throughout the book, despite the use of 62 contributors. The topics range from the quite simple and basic, such as opioids, to the potentially daunting, such as cardiac embryology. This variation is quite appropriate. The authors have aimed at avoiding the writing of a comprehensive textbook. However, although the topics do not contain the depth of discussion that one might expect from a comprehensive textbook, all the important information is concisely conveyed to the reader. The topics are generally easy to read (5–10 min), informative and can be used as a quick refresher. Each topic has clearly presented illustrations and most topics have tables summarizing key points. In addition, all the topics have an ultimate key-points section including references for further reading. I would recommend this book to all trainees wishing to get an overview about cardiac anaesthesia and intensive care. It may be useful to those working towards their exams. In addition, there are a number of topics such as: symptoms and signs of cardiac disease; invasive and non-invasive diagnostic techniques; congenital heart disease; and pregnancy, to name a few, that would be of interest to the non-cardiac anaesthetist (trainee or consultant). This book can be a useful quick reference for an established cardiac anaesthetist. A. Vohra *Manchester, UK

Preliminary Experience with Dexmedetomidine in Pediatric Anesthesia

To the Editor: We agree with the editorial comments of Tobin et al. (1), in the editorial in the current issue of Anesthesia & Analgesia. We conducted our study (2) hoping to pave the way for future investigations on dexmedetomidine in the pediatric population. The concurrent publication of four manuscripts about dexmedetomidine in children suggests that pediatric anesthesiologists believe that dexmedetomidine has an important clinical role in pediatric anesthesiology. Although our results suggest potential beneficial effects, widespread use in children can only be recommended after thorough investigation. As pointed out in the editorial, the current literature lacks dose-response guidelines for the use of dexmedetomidine in pediatrics. Tobias and Bergenbosch (3) described doses ranging from 0.2 to 0.75 μg/kg/h in various pediatric case reports, similar to adult doses ranging from 0.2–2.5 μg/kg/h (4). In our study, we used a dose of 0.5 μg/kg/h, similar to the previously described doses. Despite the relatively small sample size in our study, we were able to demonstrate beneficial hemodynamic and neuroendocrine effects of dexmedetomidine compared with placebo. We used dexmedetomidine as an adjuvant to the anesthetic protocol that was standardized in both study arms, to evaluate its additional effects on current anesthetic management. Although there were no differences between anesthetic concentrations in both groups, we believe the specific hemodynamic effects of dexmedetomidine preclude using arterial blood pressure and heart rate to guide intraoperative titration. A more precise method of monitoring depth of anesthesia, perhaps by using processed electroencephalogram, is needed to guide intraoperative titration of dexmedetomidine. Finally, we strongly agree that more study is needed to understand the safety and efficacy of dexmedetomidine in pediatric patients. Cooperation among research institutes, pharmaceutical companies, and funding agencies appears crucial to fill the frequently encountered gap in clinical trials investigating new drugs in pediatrics. Ahmed M. Mukhtar, MD Anesthesiology Department Pediatric Cardiac Anesthesia Unit [email protected] Eman M. Obayah, MD Amira M. Hassona Biochemistry Department Cairo University, Egypt

Surgical Interruption of Patent Ductus Arteriosus in a Child With Severe Aortic Stenosis: Anesthetic Considerations

PATENT DUCTUS ARTERIOSUS (PDA) is among the most common congenital heart diseases 1 Schwartz A.J. Campbell F.W. Pathophysiological approach to congenital heart disease. in: Lake C.L. Pediatric Cardiac Anesthesia. Appleton and Lange, Stamford, CT1998: 7-20 Google Scholar and is often associated with other cardiac defects (eg, ventricular septal defect, tetralogy of Fallot, transposition of great arteries). Early series of children requiring repair of PDA reported an incidence of clinical aortic stenosis (AS) of 3% to 10%. 2 Bonham-Carter R.E. Walker C.H.M. Matthews M.B. et al. Patent ductus arteriosus with an abnormal aortic valve. Br Heart J. 1955; 17: 255-261 Crossref PubMed Scopus (4) Google Scholar The treatment options for PDA include surgical interruption, video-assisted thoracoscopic surgical clipping, 3 Laborde F. Folliguet T. Batisse A. et al. Video-assisted thoracoscopic surgical interruption: The technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg. 1995; 110: 1681-1685 Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and coil embolization or device closure of the PDA in the catheterization laboratory. 4 Rosen D.A. Rosen K.R. Anomalies of the aortic arch and valve. in: Lake C.L. Pediatric Cardiac Anesthesia. Appleton and Lange, Stamford, CT1998: 431-489 Google Scholar The presence of severe AS can adversely affect the intraoperative course in a patient undergoing surgical interruption of PDA. A patient is described in whom surgical interruption of PDA was done in the presence of severe AS.

Pediatric Cardiac Anesthesia, 4th Edition.

Pediatric Cardiac Anesthesia, 4th Edition.

Pediatric Cardiac Anesthesia, 4th Edition.

Pediatric Cardiac Anesthesia, 4th Edition.

A Celebration of 75 Years Honoring Ralph Milton Waters, M.D.: Mentor to a Profession. Proceedings, The Ralph M. Waters Symposium on Professionalism in Anesthesiology, Madison, Wisconsin, 2002.

A Celebration of 75 Years Honoring Ralph Milton Waters, M.D.: Mentor to a Profession. Proceedings, The Ralph M. Waters Symposium on Professionalism in Anesthesiology, Madison, Wisconsin, 2002.

Book Review: Pediatric Cardiac Anesthesia—4th Edition.

Book Review: Pediatric Cardiac Anesthesia—4th Edition.

Difficult intubation in pediatric cardiac anesthesia

Objective: The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. Design: Retrospective analysis Setting: Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital Participants: All children undergoing congenital heart surgery Interventions: Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. Measurements and main results: A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). Conclusion: The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.

Cardiac anaesthesia: the last 10 years.

Cardiac anaesthesia: the last 10 years.

Paediatric cardiac anaesthesia in the UK--current controversies.

This paper is a personal view by the authors of some of the major controversies that currently face paediatric cardiac anaesthetists in the United Kingdom (UK); it should be noted that our views are not necessarily representative of other UK anaesthetists working in this field. The issues that we have chosen to discuss have been the subject of important changes in national or local policies in the last few years, and that have had (or will have) a substantial impact on our clinical practice.

Recent advances in paediatric cardiac anaesthesia.

Recent advances in paediatric cardiac anaesthesia.