Utilisation of a post-Fontan management pathway reduces chest tube drainage and hospital readmission rates.

BACKGROUND: Complications following the Fontan procedure include prolonged pleural drainage and readmission for effusions. To address these complications, a post-Fontan management pathway was implemented with primary goals of reducing chest tube duration/reinsertion rates and decreasing hospital length of stay and readmissions. METHODS: Fontan patients were identified by retrospective chart review (2017-2019) to obtain baseline data for chest tube duration/reinsertion rates, hospital length of stay, and readmission rates for effusion. A post-Fontan management pathway was implemented (2020-2021) utilising post-operative vasopressin, nasal cannula oxygen until chest tube removal, and discharge regimen of three times daily diuretics, sildenafil, and afterload reducing medications. Patients were followed to evaluate primary outcomes. RESULTS: The pre- and post-pathway groups were similar in single ventricle morphology, demographics, and pre-operative haemodynamics. Forty-three and 36 patients were included in the pre- and post-pathway cohorts, respectively. There were statistically significant reductions in chest tube duration (8 vs. 5 days, p ≤ 0.001), chest tube output on post-operative day 4 (20.4 vs. 9.9 mL/kg/day, p = 0.003), and hospital readmission rates for effusion (13[30%] vs. 3[8%], p = 0.02) compared to baseline. There was an absolute reduction in hospital length of stay (11 vs. 9.5 days, p = 0.052). When combining average cost savings for the Fontan hospitalisations, readmissions for effusion, and cardiac catheterisations within 6 months of Fontan completion, there was a $325,144 total cost savings for 36 patients following pathway implementation. CONCLUSION: Implementation of a post-Fontan management pathway resulted in significant reductions in chest tube duration and output, and readmission rates for effusion in the perioperative period.

What an anesthesiologist should know about pediatric arrhythmias.

Identifying and treating pediatric arrhythmias is essential for pediatric anesthesiologists. Pediatric patients can present with narrow or wide complex tachycardias, though the former is more common. Patients with inherited channelopathies or cardiomyopathies are at increased risk. Since most pediatric patients present for anesthesia without a baseline electrocardiogram, the first identification of an arrhythmia may occur under general anesthesia. Supraventricular tachycardia, the most common pediatric tachyarrhythmia, represents a broad category of predominately narrow complex tachycardias. Stimulating events including intubation, vascular guidewire manipulation, and surgical stimulation can trigger episodes. Valsalva maneuvers are unreliable as treatment, making adenosine or other intravenous antiarrhythmics the preferred acute therapy. Reentrant tachycardias are the most common supraventricular tachycardia in pediatric patients, including atrioventricular reciprocating tachycardia (due to a distinct accessory pathway) and atrioventricular nodal reentrant tachycardia (due to an accessory pathway within the atrioventricular node). Patients with ventricular preexcitation, often referred to as Wolff-Parkinson-White syndrome, have a wide QRS with short PR interval, indicating antegrade conduction through the accessory pathway. These patients are at risk for sudden death if atrial fibrillation degenerates into ventricular fibrillation over a high-risk accessory pathway. Automatic tachycardias, such as atrial tachycardia and junctional ectopic tachycardia, are causes of supraventricular tachycardia in pediatric patients, the latter most typically noted after cardiac surgery. Patients with inherited arrhythmia syndromes, such as congenital long QT syndrome, are at risk of developing ventricular arrhythmias such as polymorphic ventricular tachycardia (Torsades de Pointes) which can be exacerbated by QT prolonging medications. Patients with catecholaminergic polymorphic ventricular tachycardia are at particular risk for developing bidirectional ventricular tachycardia or ventricular fibrillation during exogenous or endogenous catecholamine surges. Non-selective beta blockers are first line for most forms of long QT syndrome as well as catecholaminergic polymorphic ventricular tachycardia. Anesthesiologists should review the impact of medications on the QT interval and transmural dispersion of repolarization, to limit increasing the risk of Torsades de Pointes in patients with long QT syndrome. This review explores the key anesthetic considerations for these arrhythmias.

Anesthetic Considerations for Patients With Williams Syndrome.

Williams syndrome (WS) is a relatively rare congenital disorder which manifests across multiple organ systems with a wide spectrum of severity. Cardiovascular anomalies are the most common and concerning manifestations of WS, with supravalvar aortic stenosis present in up to 70% of patients with WS. Although a relatively rare disease, these patients frequently require sedation or anesthesia for a variety of medical procedures. The risk of sudden death in this population is 25 to 100 times that of the general population, with many documented deaths associated with sedation or anesthesia. This increased risk coupled with a disproportionately frequent need for anesthetic care renders it prudent for the anesthesiologist to have a firm understanding of the manifestations of WS. In the following review, the authors discuss pertinent clinical characteristics of WS along with particular anesthetic considerations for the anesthesiologist caring for patients with WS presenting for non-cardiac surgery.

Apneic oxygenation via nasal cannula for intubation of a premature neonate with multiple airway anomalies.

Intubating a neonate under non-emergent conditions may be quite stressful, even for experienced providers, due to the potential for rapid oxygen desaturation. Pulmonary physiology and increased metabolic oxygen demand in this patient population contribute to accelerated oxygen desaturation during induction of anaesthesia and intubation. Using a nasal cannula, placed prior to induction of anaesthesia and left in place until the airway is secured, is a simple and effective way to provide apneic oxygenation and may help maintain adequate oxygen saturation. This technique may be particularly useful for patients who require additional time for intubation, including those with suspected difficult airways.

Evaluation of Dynamic Ultrasound for Arterial Access in Children Undergoing Cardiac Surgery.

OBJECTIVE: To evaluate the effect of dynamic ultrasound (US) on the need for surgical intervention to achieve successful arterial cannulation in the pediatric cardiac surgery population. DESIGN: Retrospective, observational study. SETTING: Single, academic, pediatric hospital in the United States. PARTICIPANTS: The study comprised 3,569 consecutive patients who had an arterial catheter placed in the operating room before undergoing congenital heart surgery between January 2004 and September 2016. INTERVENTIONS: Dynamic US was used in 2,064 cases (57.83%) to obtain arterial access. Arterial cannulation by palpation was performed in the remaining 37.8% of cases. Surgical cutdown for arterial access was required in 192 cases after failed cannulation attempts by the anesthesia team. MEASUREMENTS AND MAIN RESULTS: Use of US was associated with an overall decrease in the need for surgical access from 10.43% to 1.70% (p < 0.0001). In patients younger than 30 days, US decreased the rate of surgical access, from 19.62% to 2.65% (p < 0.0001). This significant decrease also was observed in patients 1 to 6 months old (13.93% v 3.73%; p < 0.0001), 7 to 12 months old (7.34% v 0.00%, p < 0.0001), and older than 2 years (1.12% v 0%; p = 0.0083). For children between 13 and 24 months old, there was no statistically significant benefit to using US for avoiding surgical access (3.33% v 0.79%; p = 0.1411). Throughout all age groups, use of US was associated with a significant improvement in optimal arterial line location, defined as placement in an upper extremity (73.75% v 91.13%; p < 0.0001). CONCLUSIONS: Dynamic US resulted in a significant reduction in surgical intervention to achieve arterial cannulation in children presenting for cardiac surgery.

Development of a Rescue Echocardiography Protocol for Noncardiac Surgery Patients.

Intraoperative transesophageal echocardiography (TEE) is a helpful diagnostic tool when hemodynamic compromise is encountered during noncardiac surgery. At our institution, a Rescue Echo Protocol was created to provide a structured means for requesting and performing a rescue TEE. We analyzed our institutional utilization of this service and found that it was used throughout the spectrum of patients' American Society of Anesthesiologists classifications and surgical services. We demonstrated that 72.9% of rescue examinations resulted in a change in management, supporting the use of TEE as a diagnostic tool during hemodynamic compromise.

Incidental Discovery of an Atypical Cardiac Tumor.

Primary cardiac tumors are rare, present in roughly 0.05% of the population. Cardiac papillary fibroelastoma (CPF) is the second most common, accounting for 10% of primary cardiac tumors.[1] Most cases of CPFs are discovered incidentally on autopsy; however, they may present clinically with systemic embolization or heart failure symptoms. The recommended treatment for symptomatic CPF patients is surgical resection.[1] Treatment in asymptomatic patients remains somewhat controversial with incidentally discovered tumors presenting a clinical dilemma. We present a case of an atypically located CPF that was discovered incidentally on intraoperative transesophageal echocardiography (TEE) during a routine coronary artery bypass graft operation. This case highlights several important points for cardiac anesthesiologists. The first is the importance of performing a comprehensive intraoperative TEE. Next, this case reinforces the broad utility of TEE for evaluation of intracardiac tumors. Finally, this case demonstrates the importance of precise localization of intracardiac tumors.