Spinal surgery in the univentricular heart--is it viable?

INTRODUCTION: The management of patients with Fontan physiology who undergo scoliosis surgery is difficult. The purpose of this article was to describe our experience in the management of patients with Fontan circulation undergoing spinal surgery for correction of scoliosis. MATERIALS AND METHODS: This was a retrospective study including patients with Fontan physiology who underwent spinal orthopaedic surgery. Anaesthetic management, post-operative complications, paediatric intensive care unit and total hospital stay, and the need for blood transfusions were analysed. RESULTS: We identified eight children with Fontan physiology who had undergone spinal surgery from 2000 to 2010. All patients were receiving cardiac medications at the time of spinal surgery. The mean age at surgery was 14.8 years (range 12-21). In all, three patients needed inotropic support with dopamine (3, 5, and 8 µg/kg/min), which was started during surgery. During the immediate post-operative period, one patient died because of hypovolaemic shock caused by massive bleeding and dysrythmia. Mean blood loss during the post-operative period was 22.2 cc/kg (7.8-44.6). Surgical drainages were maintained for a mean time of 3 days (range 1-7). The mean hospital stay was 9.2 days (range 6-19). Pleural effusions developed in two patients. On follow-up, one patient presented with thoracic pseudarthrosis and another with a serohaematoma of the surgical wound. CONCLUSIONS: Spinal surgery in patients with Fontan circulation is a high-risk operation. These patients must be managed by a specialised team.

[Early postoperative complications after scoliosis surgery]. / Complicaciones médicas precoces en el postoperatorio de cirugía de escoliosis.

Several medical complications can occur after scoliosis surgery in children and adolescents. New surgical techniques have allowed greater degrees of scoliosis correction but have also increased the possibility of postsurgical deficit due to their greater aggressivity. We analyzed the early postsurgical complications of scoliosis surgery in a pediatric intensive care unit over a 10-year period. Seventy-six surgical procedures were performed. Of these, no complications occurred in 55 (73%). Chest X-ray revealed pulmonary atelectasia in 8 patients (10%) and pleural effusion in 7 patients (9%). Symptoms and signs of infection related to surgery were observed in only 6 children (8%). The absence of severe medical complications may be related to new surgical techniques and an experienced team.

[Early postoperative complications of thoracoscopy versus thoracotomy in pediatric idiopathic scoliosis]. / Estudio comparativo de las complicaciones postoperatorias inmediatas de la toracoscopia frente a la toracotomía en la escoliosis idiopática infantil.

INTRODUCTION: Thoracoscopic surgery has been used for anterior release, discectomy, and fusion in severe scoliosis or kyphosis. The indications of thoracoscopy for the treatment of pediatric spinal deformity are similar to those of thoracotomy-based spinal surgery. OBJECTIVE: We designed a comparative study to observe the immediate complications in the postoperative period after thoracoscopy or thoracotomy for scoliosis in the pediatric population. MATERIAL AND METHODS: The postsurgical complications of 63 interventions for idiopathic scoliosis over a 10-year period were analyzed. Conventional thoracotomy was used in 37 interventions (59 %) and thoracoscopy was used in 26 (41 %). RESULTS: In patients treated with the thoracolumbar endoscopic procedure, oral nutrition was resumed earlier, the mean length of hospital stay was lower, and debit drainage or requirement of surgical drainage were lower. CONCLUSIONS: Fewer immediate postsurgical complications were observed in scoliosis surgery when thoracoscopy was used.

[Ventilation in special situations. Mechanical ventilation in congenital cardiopathies and pulmonary hypertension]. / Ventilación en situaciones especiales. Ventilación mecánica en cardiopatías congénitas e hipertensión pulmonar.

The cardiovascular and respiratory systems act as a functional unit. Mechanical ventilation modifies pulmonary volumes, which generates changes in autonomic nervous system reactivity and provokes tachy- or brady-cardia (depending on the tidal volume used). Mechanical ventilation also decreases cardiac filling volumes (pre-load) and alters pulmonary vascular resistances. In addition, intrathoracic pressures are enlarged, which usually produces a decrease in right atrium filling and an increase in right ventricle afterload. If coronary flow is impaired, myocardial contractility is reduced. However, if cardiac failure is present, mechanical ventilation is especially beneficial because it corrects hypoxia and respiratory acidosis, decreases the work of breathing, and improves stroke volume. Mechanical ventilation in congenital heart diseases is indicated either as lifesaving support or as physiopathological treatment to modify the ratio between pulmonary and systemic flow. As a general rule, if excessive pulmonary blood flow is present, the aim of respiratory support is to increase pulmonary vascular resistance by using high levels of airway pressure and even by delivering FiO2<21%. When there is low pulmonary flow, the lowest possible intrathoracic pressures should be used, especially in cases of pulmonary hypertension, which will also require high FiO2. However, mechanical ventilation has adverse effects and consequently it must be stopped as early as possible, once the child is stable and requires minimal cardiopulmonary support. Weaning can even be performed in the operating room, when the surgical procedure is finished. When this is not possible, weaning should be performed in the pediatric intensive care unit. Because there are no criteria for successful withdrawal of mechanical support in congenital heart disease, general pediatric criteria should be used.