Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery.

BACKGROUND: The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. METHODS: In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. RESULTS: A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. CONCLUSIONS: Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

The Effect of Intraoperative Transesophageal Echocardiography Probe Placement on the Endotracheal Tube Cuff Pressure in Adult Patients Undergoing On-Pump Cardiac Surgery.

OBJECTIVES: The study was directed toward documentation of the effect of transesophageal echocardiography (TEE) probe insertion on the endotracheal tube cuff pressure (CP) in adult patients undergoing on-pump coronary bypass surgery. The primary objective of this study was to assess whether CP reaches supranormal pressures during the different stages of intraoperative TEE examination. The secondary objective was to observe the effect of TEE probe placement on the ventilation parameters. DESIGN: A prospective observational study. SETTING: At a tertiary care cardiac center. PARTICIPANTS: Thirty-four cardiac surgical patients older than 18 years of age who required intraoperative TEE examination. INTERVENTIONS: TEE probe insertion. MEASUREMENTS AND MAIN RESULTS: Following the induction of general anesthesia and tracheal intubation, a TEE probe was introduced. The endotracheal tube CP was recorded at 5 time zones: Before TEE probe insertion, during the insertion of the probe, during probe manipulation, probe in the transgastric position, and during removal of the probe. A nonparametric test was used for comparing intracuff pressure between pairs of time zones. There was a statistically significant difference in CP values between the baseline and those during different time zones (chi-square test = 134.77, degrees of freedom = 4, p = 0.001). There was a statistically significant difference in the peak pressure between different time points compared to baseline (p = 0.0001). CONCLUSIONS: TEE probe placement in patients with tracheal intubation may be associated with a significant increase in CP well above the baseline pressure. With the possibility of the mean arterial pressures during cardiopulmonary bypass being substantially lower than expected, the findings of the current study raised the concern of predisposing the tracheal mucosa to hypoperfusion, with subsequent temporary or permanent tracheal damage. Hence, at least a baseline estimation of the endotracheal tube CP at the time of tracheal intubation, with the help of a pressure gauge in the operating room, may be considered as a safe practice.

Central Venous Catheter Tip Malposition After Internal Jugular Vein Cannulation in Pediatric Patients With Congenital Heart Disease.

OBJECTIVES: The primary objective of the study was to identify the incidence of catheter tip malposition as determined by postoperative radiography after central venous cannulation by right and left internal jugular venous routes in pediatric cardiac surgical patients. The secondary objective was to determine the relative risk of malposition between the 2 approaches into specific major thoracic veins other than the right superior vena cava. DESIGN: A prospective observational study. SETTING: A tertiary cardiac care center. PARTICIPANTS: Pediatric patients undergoing cardiac surgery INTERVENTIONS: Internal jugular vein cannulation with ultrasound guidance. MEASUREMENTS AND MAIN RESULTS: Two hundred pediatric patients undergoing cardiac surgeries for cardiac anomalies with Risk Adjustment in Congenital Heart Surgery scores of 1- to-6 were included in the study. After anesthetic induction, 50% of the patients were cannulated via the right internal jugular vein (RIJV group, n = 100), and the other 50% via the left internal jugular vein (LIJV group, n = 100). The position of the catheter tip was ascertained by a plain chest x-ray. The central venous catheter tip was deemed to be malpositioned if the tip was in the ipsilateral or contralateral subclavian vein or in the contralateral internal jugular vein. In the RIJV group, 4% of the patients had the central venous catheter tip in a malposition (4/100). In the LIJV group, 6 of the 100 patients had a left superior vena cava and were excluded. In the rest of the LIJV group, the central venous catheter tip was in a malposition in 22.3% of patients (21/94, relative risk: 6.90, p < 0.001). Malposition into the right subclavian vein was more frequent with the left internal jugular vein access (11/94, 11.7%) compared with the right internal jugular vein access (relative risk: 13.12, p = 0.015). CONCLUSIONS: The incidence of a malposition of a central venous catheter tip after either right or left internal jugular vein approach was ascertained. The relative risk of a malposition occurring with the left internal jugular approach was higher, and the most common site of malposition was in the right subclavian vein.

Assessment of stress response attenuation with caudal morphine using a surrogate marker during pediatric cardiac surgery.

BACKGROUND: Measurement of biomarkers representing sympathetic tone and the surgical stress response are helpful for objective comparison of anesthetic protocols. AIMS: The primary aim was to compare changes in chromogranin A levels following pump pediatric cardiac surgery between children who received bolus caudal morphine and those who received a conventional intravenous narcotic-based anesthesia regime. The secondary objectives were to compare hemodynamic responses to skin incision and the magnitude of the rise in blood sugar values between the groups. SETTINGS AND DESIGN: A prospective observational study at a tertiary cardiac center. MEASUREMENTS AND METHODS: Sixty pediatric cardiac surgical patients were randomized to Group I [n= 30] to receive intravenous narcotic-based anesthesia and Group II [n = 30] to receive single-shot caudal morphine. Baseline and postoperative chromogranin A levels, the hemodynamic response to skin incision, changes in blood sugar levels, and the total intravenous narcotic dose administered were recorded for each participant. STATISTICAL ANALYSIS: Pearson's Chi-squared test was used for comparison of categorized variables, and Mann-Whitney test was used for the analysis of continuous data. RESULTS: Changes in chromogranin A levels and blood sugar levels were comparable in both groups. Group II received a lower narcotic dosage (P ≤ 0.001), and the response to skin incision as reflected by systolic pressure rise was less (P = 0.006). CONCLUSIONS: Surgical stress response attenuation was similar to caudal morphine as compared with intravenous narcotic-based anesthesia techniques as reflected by a similar increase in chromogranin A levels.

Authentication of Radial Versus Femoral Arterial Pressure Waveform-Derived Cardiac Output With Transesophageal Echocardiography-Derived Cardiac Output Measurements in Patients Undergoing On-Pump Coronary Bypass Surgery.

OBJECTIVE: The aim of this study was to ascertain if arterial waveform-derived cardiac output measurements from radial and femoral cannulation sites were reliable as compared with transesophageal echocardiography (TEE)-derived cardiac output (CO) values, and which of the CO measurements derived from radial and the femoral arterial pressure waveforms closely tracked simultaneously measured TEE-derived CO values. This study also aimed to ascertain if cardiopulmonary bypass (CPB) would impact the accuracy of arterial pressure-derived CO values from either of the 2 sites. DESIGN: A prospective observational study. SETTING: Tertiary care cardiac center. PARTICIPANTS: Cardiac surgical patients undergoing on-pump primary coronary artery bypass surgery. INTERVENTIONS: Waveform-derived CO monitoring through radial and femoral artery cannulation using a FloTrac/Vigileo system. MEASUREMENTS AND MAIN RESULTS: Twenty-seven consecutive cardiac surgical patients undergoing on-pump primary coronary artery bypass surgery were included in the study. Cardiac output was measured sequentially by the arterial pressure waveform analysis method from radial and femoral arterial sites and compared with simultaneously measured TEE-derived CO. Cardiac output data were obtained in triplicate at 6 predefined time intervals: before and after sternotomy, 5, 15, and 30 minutes after separation from CPB and prior to shifting the patient out of the operating room. The overall bias of the study was 0.11 and 0.27, the percentage error was 19.31 and 18.45, respectively, for radial and femoral arterial waveform-derived CO values as compared with TEE-derived CO measurements. The overall precision as compared with the TEE-derived CO values was 16.94 and 15.95 for the radial and femoral cannulation sites, respectively. The bias calculated by the Bland-Altman method suggested that CO measurements from the radial arterial site were in closer agreement with TEE-derived CO values at all time periods, and the relation was not affected by CPB. However, percentage error and precision calculations showed that CO values derived from the femoral arterial waveform were in closer agreement, albeit marginally, with the TEE values at all time points. CONCLUSIONS: Both the radial and femoral arterial pressure waveform-derived CO measurements were comparable with the TEE measurements during the various stages of the cardiac surgery. Although the femoral cannulation site provided marginally better correlation with the reference TEE-derived CO values based on the precision and percentage error analysis; this may not be significant clinically and either of the arterial cannulation sites can be used reliably for CO measurements in clinical practice. Cardiopulmonary bypass had no impact on the radial and femoral artery pressure waveform-derived CO measurements.