Perioperative management of infants undergoing fundoplication and gastrostomy after stage I palliation of hypoplastic left heart syndrome.

Infants with hypoplastic left heart syndrome (HLHS) represent a high-risk population when they present for noncardiac surgery. To assist clinicians in the care of these infants, we present our experience of 36 HLHS patients who underwent abdominal surgery after stage I palliation. We reviewed patients with HLHS who underwent gastrostomy and/or fundoplication after stage I palliation during an 18-month period. We assessed the impact of preoperative echocardiographic predictors and regional anesthesia on use of intraoperative inotropes, extubation in the OR, perioperative instability, postoperative escalation of care, and length of hospital and intensive care unit stay. Of 39 abdominal operations, all but 2 were performed with open laparotomy. There was a positive association between regional anesthesia and instability during induction. Escalation of respiratory care occurred in 9 (23.1%) cases, and escalation of hemodynamic care occurred in 6 (15.4%) cases. Neoaortic valve insufficiency was associated with increased length of stay, and ventricular outflow obstruction was associated with escalation of hemodynamic care. Extubation in the OR was successful in 31 cases (79.5%). In-hospital death occurred in 1 patient (2.7%). HLHS infants often undergo abdominal surgery, but intraoperative instability and need for escalation of care is common. Specific echocardiographic findings were associated with length of stay and escalation of care. Regional anesthesia was associated with transient intraoperative instability but not with other adverse outcomes.

Genetic variation in complement component 2 of the classical complement pathway is associated with increased mortality and infection: a study of 627 patients with trauma.

BACKGROUND: Trauma is a disease of inflammation. Complement Component 2 (C2) is a protease involved in activation of complement through the classical pathway and has been implicated in a variety of chronic inflammatory diseases. We hypothesized that genetic variation in C2 (E318D) identifies a high-risk subgroup of patients with trauma reflecting increased mortality and infection (ventilator-associated pneumonia [VAP]). Consequently, genetic variation in C2 may stratify patient risk and illuminate underlying mechanisms for therapeutic intervention. METHODS: DNA samples from 702 patients with trauma were genotyped for C2 E318D and linked with covariates (age: mean 42.8 years, gender: 74% male, ethnicity: 80% white, mechanism: 84% blunt, injury severity score: mean 25.0, admission lactate: mean 3.13 mEq/L) and outcomes: mortality 9.9% and VAP: 18.5%. VAP was defined by quantitative bronchoalveolar lavage (> 10). Multivariate regression analysis determined the relationship of genotype and covariates to risk of death and VAP. However, patients with injury severity score > or = 45 were excluded from the multivariate analysis, as magnitude of injury overwhelms genetics and covariates in determining outcome. RESULTS: Fifty-two patients (8.3%) had the high-risk heterozygous genotype, associated with a significant increase in mortality and VAP. CONCLUSION: In 702 patients with trauma, 8.3% had a high-risk genetic variation in C2 associated with increased mortality (odds ratio = 2.65) and infection (odds ratio = 2.00). This variation: (1) identifies a previously unknown high-risk group for infection and mortality; (2) can be determined at admission; (3) may provide opportunity for early therapeutic intervention; and (4) requires validation in a distinct cohort of patients.

Risks of noncardiac operations and other procedures in children with complex congenital heart disease.

BACKGROUND: Children with complex congenital heart disease entail risk when undergoing noncardiac operations and other procedures requiring general anesthesia. To address concerns regarding intraoperative instability, need for postoperative mechanical ventilation, and postoperative hospital length of stay (LOS), we present our 5-year experience with 71 patients with complex congenital heart disease who underwent 252 surgical procedures. METHODS: We reviewed the records of all patients from July 2006 to January 2011 who underwent a cardiac procedure with a Risk Adjustment for Congenital Heart Surgery-1 score of 6, and included all who underwent noncardiac procedures during this interval. Perioperative data were gathered to identify patients at risk for induction and maintenance instability, need for postoperative mechanical ventilation, and postoperative hospital LOS. Univariate predictors of these outcome variables were evaluated and entered into stepwise regression algorithms to determine independent variables. RESULTS: We identified 252 procedures that were performed on 71 patients during the study interval. These procedures were performed under 173 general anesthesias. Using each general anesthesia as a case, induction instability was independently associated with stage of palliation before cavopulmonary shunt, case complexity, and preoperative use of angiotensin-converting enzyme inhibitor in a multivariate logistic regression. Maintenance instability was independently associated with case complexity and preoperative use of digoxin and inotropes. Among the 145 cases where the patient was not intubated before the procedure, postoperative need for mechanical ventilation was associated only with preoperative hospital LOS exceeding 14 days. Finally, the resulting linear regression model showed postoperative hospital LOS was independently associated with preoperative hospital LOS exceeding 14 days, presence of moderate ventricular dysfunction, preoperative use of an inotrope, and negatively associated with use of digoxin. CONCLUSIONS: Within this population, we have identified independent risk factors for specific clinical outcomes. Patients before stage II palliation, undergoing more invasive procedures, and receiving inotropes, angiotensin-converting enzyme inhibitors, or digoxin appear to be at risk for intraoperative hemodynamic instability. Patients with preoperative hospital LOS exceeding 14 days appear to be at greater risk for requiring postoperative mechanical ventilation. Patients with preoperative LOS exceeding 14 days, with ventricular dysfunction, receiving inotropes, and not receiving digoxin appear to be at risk for protracted hospitalization. Application of these results should assist clinicians in assessing perioperative risk.