Selected 2021 Highlights in Congenital Cardiac Anesthesia.

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist and was published in 2021. After a search of the United States National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2021. The authors of this manuscript considered the following topics noteworthy to be included in this review: risk stratification in adult congenital heart disease surgery, physician burnout in pediatric cardiac anesthesia, transfusion practice in pediatric congenital heart surgery, and racial disparity and outcomes in pediatric patients with congenital heart disease.

Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial.

BACKGROUND: Acquisition of transthoracic echocardiographic (TTEcho) images in children often requires sedation. The optimal sedative for TTEcho has not been determined. Children with congenital heart disease are repeatedly exposed to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population. METHODS: A prospective, randomized, double-blind trial enrolled 280 children 3-24 months of age undergoing outpatient TTEcho, comparing 2.5 µg·kg intranasal dexmedetomidine to 5 mg·kg oral pentobarbital. Rescue sedation, for both groups, was intranasal dexmedetomidine 1 µg·kg. The primary outcome was adequate sedation within 30 minutes without rescue sedation, assessed by blinded personnel. Secondary outcomes included number of sonographer pauses, image quality in relation to motion artifacts, and parental satisfaction. RESULTS: Success rates with a single dose were not different between sedation techniques; 85% in the pentobarbital group and 84% in the dexmedetomidine group (P = .8697). Median onset of adequate sedation was marginally faster with pentobarbital (16.5 [interquartile range, 13-21] vs 18 [16-23] minutes for dexmedetomidine [P = .0095]). Time from drug administration to discharge was not different (P = .8238) at 70.5 (64-83) minutes with pentobarbital and 70 (63-82) minutes with dexmedetomidine. Ninety-five percent of sedation failures with pentobarbital and 100% of dexmedetomidine failures had successful rescue sedation with intranasal dexmedetomidine. CONCLUSIONS: Intranasal dexmedetomidine was comparable to oral pentobarbital sedation for TTEcho sedation in infants and did not increase the risk of clinically important adverse events. Intranasal dexmedetomidine appears to be an effective "rescue" sedative for both failed pentobarbital and dexmedetomidine sedation. Dexmedetomidine could be a safer option for repeated sedation in children, but further studies are needed to assess long-term consequence of repeated sedation in this high-risk population.

Interventions designed using quality improvement methods reduce the incidence of serious airway events and airway cardiac arrests during pediatric anesthesia.

BACKGROUND: Although serious complications during pediatric anesthesia are less common than they were 20 years ago, serious airway events continue to occur. Based on Quality Improvement (QI) data from our institution, a QI project was designed to reduce the incidence of serious airway events and airway cardiac arrests. METHODS: A quality improvement team consisting of members of the Department of Anesthesia was formed and QI data from previous years were analyzed. The QI team developed a Smart Aim, Key Driver Diagram, and specific Interventions that focused on the accessibility of emergency drugs, the use of nondepolarizing muscle relaxants for endotracheal intubation in children 2 years and younger, and the presence of anesthesia providers until emergence from anesthesia in high-risk patients. RESULTS: The percentage of cases where muscle relaxants were utilized in children 2 years and younger for endotracheal intubation and where atropine and succinylcholine were readily available increased at both our base and outpatient facilities. Over the 2.5-year study period, the incidence of serious airway events and airway cardiac arrests was reduced by 44% and 59%, respectively compared to the previous 2-year period. CONCLUSION: We utilized QI methodology to design and implement a project which led to greater standardization of clinical practice within a large pediatric anesthesia group. Based on an understanding of system issues impacting our clinical practice, we designed and tested interventions that led to a significant reduction in the incidence of serious airway events and airway cardiac arrests.

Case discussion and root cause analysis: bupivacaine overdose in an infant leading to ventricular tachycardia.

An otherwise healthy 11-month-old, 8-kg infant presented for an elective circumcision. After a penile block with an excessive dose of 0.5% bupivacaine, the patient progressed to ventricular tachycardia. He was resuscitated with intralipid and had an uneventful recovery. The case was classified as a serious safety event, and a team was created to perform a root cause analysis. A sequence of events was constructed from gathered data, and policies and procedures were reviewed. Proximate cause was determined to be the failure of the surgeon, anesthesiologist, nurse, and scrub technician to communicate about the maximum dose of local anesthetic allowed before the medication being drawn up. Interventions were developed to target the proximate and contributing causes.

Implementation of a Peer-to-Peer Support Program in a Quaternary Pediatric Medical Center.

Healthcare worker burnout is a growing epidemic associated with multiple negative outcomes. Compounding the routine stresses of clinical practice, involvement in adverse events can be emotionally devastating. Healthcare organizations have an obligation to mitigate burnout and promote engagement and resiliency. Many institutions have launched wellness initiatives, but the value of these programs is unclear. Here, we describe the implementation of a peer-to-peer support program at our quaternary pediatric medical center. This proactive program is unique in its referral process and scope and has demonstrated efficacy in mitigating the emotional impact of adverse effects. In total, our institution has trained 125 peer supporters. Since initiation, there have been a total of 2187 referrals made to the program. Data collected in 2022 from these referrals showed a 60.3% (n = 1220) response rate to the offer of support. A survey was sent to frontline clinicians from divisions with trained supporters. Of 963 respondents, 71.8% (n = 691) agreed that this program was a valuable resource, and 81.3% (n = 783) recommended peer support to be offered to those involved in adverse and stressful events. Our experience supports that the implementation of a proactive, peer-to-peer support program is both feasible and valuable.

Evaluation of pediatric near-infrared cerebral oximeter for cardiac disease.

BACKGROUND: Cerebral hypoxia-ischemia remains a complication in children with congenital heart disease. Near-infrared spectroscopy can be utilized at the bedside to detect cerebral hypoxia-ischemia. This study aimed to calibrate and validate an advanced technology near-infrared cerebral oximeter for use in children with congenital heart disease. METHODS: After institutional review board approval and parental consent, 100 children less than 12 years and less than 40 kg were enrolled. Phase I (calibration) measured arterial and jugular venous saturation (SaO(2), SjO(2)) by co-oximetry simultaneously with device signals to calibrate an algorithm to determine regional cerebral saturation against a weighted average cerebral saturation (0.7 SjO(2) + 0.3 SaO(2)). Phase II (validation) evaluated regional cerebral saturation from the algorithm against the weighted average cerebral saturation by correlation, bias, precision, and A(Root Mean Square) assessed by linear regression and Bland-Altman analysis. RESULTS: Of 100 patients, 86 were evaluable consisting of 7 neonates, 44 infants, and 35 children of whom 55% were female, 79% Caucasian, and 41% with cyanotic disease. The SaO(2) and regional cerebral saturation ranged from 34% to 100% and 34% to 91%, respectively. There were no significant differences in subject characteristics between phases. For the entire cohort, A(RMS), bias, precision, and correlation coefficient were 5.4%, 0.5%, 5.39%, and 0.88, respectively. Age, skin color, and hematocrit did not affect these values. CONCLUSIONS: This cerebral oximeter accurately measures the absolute value of cerebral saturation in children over a wide range of oxygenation and subject characteristics, offering advantages in assessment of cerebral hypoxia-ischemia in congenital heart disease.

Anesthetic implications of undiagnosed late onset central hypoventilation syndrome in a child: from elective tonsillectomy to tracheostomy.

Late onset central hypoventilation syndrome is a neurological disorder that can present with postoperative respiratory complications and delayed emergence in children after anesthesia. We present a child who had unanticipated respiratory complications following an elective tonsillectomy who eventually required a tracheostomy and long-term ventilatory support.