A prospective audit of safety issues associated with general anesthesia for pediatric cardiac magnetic resonance imaging

Background/Objectives: Cardiac MRI (CMR) is increasingly used for surgical planning and serial monitoring of children with congenital heart disease (CHD). For small children, general anesthesia (GA) is required. We describe our experience of the safety of GA for pediatric CMR, using data collected prospectively over 3 years. Methods: All consecutive infants undergoing GA for CMR at our institution, between November 2005 and May 2008, were included. Informed and written consent to participate in research investigation was acquired from the guardians of every patient prior to CMR. The cardiac anesthetist completed a standardized data collection form during each procedure. Information collected included demographics, diagnosis, surgical history, anesthetic management, significant incidents, and discharge circumstances. Results: A total of 120 patients with varying cardiac physiology and a range of hemodynamics underwent GA for CMR during the study period. Gas induction was predominantly used, even in those with impaired ventricular function. The majority (71%) of procedures were undertaken without significant incident. Minor adverse incidents were recorded in 32 patients, mild hypotension being most frequent. One major adverse event occurred. A patient with hypoplastic left heart syndrome (HLHS) suffered hypotension then cardiac arrest in the scanner. This patient was successfully resuscitated. Conclusion: Although the majority of cases were safe and without incident, the complication rate in children with CHD receiving a GA for CMR is higher than in the general pediatric population. This reinforces the need for a senior, multidisciplinary team to be involved in the care of these children during imaging.     

Propofol-ketamine mixture for anesthesia in pediatric patients undergoing cardiac catheterization

OBJECTIVE: To evaluate the safety of a propofol-ketamine mixture to induce and maintain anesthesia in spontaneously breathing pediatric patents during cardiac catheterization. DESIGN: Prospective clinical study. SETTING: Departments of Cardiothoracic Surgery, Anesthesiology, and Pediatric Anesthesiology in a university hospital. PARTICIPANTS: Forty-five children aged 6 months to 16 years with ASA grade II to III undergoing cardiac catheterization. INTERVENTIONS: Continuous intravenous infusion of a mixture of propofol (4 mg/mL) and ketamine (2 mg/mL) with spontaneous ventilation. The infusion rate was changed and additional boluses of propofol or/and ketamine were given as needed. Hemodynamic, respiratory, and other variables were recorded during the procedure and recovery. RESULTS: Mean dose of ketamine was 26 +/- 8.3 microg/kg/min and of propofol, 68.3 +/- 21.7 microg/kg/min. Changes in heart rate and mean arterial pressure of more than 20% from baseline were observed in 4 and 5 patients, respectively. A transient reduction in oxygen saturation because of hypoventilation was observed in 3 patients and responded to oxygen administration and manual assisted ventilation. No other complications were observed. CONCLUSIONS: The propofol-ketamine mixture is a safe, practical alternative for general anesthesia in pediatric patients undergoing cardiac catheterization.     

Anesthesia and the pediatric cardiac catheterization suite: a review

Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.     

Anesthetic considerations for major burn injury in pediatric patients

Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi-disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi-disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.     

Pediatric patients requiring extracorporeal membrane oxygenation in heart failure: 30‐day outcomes; mid‐ and long‐term survival. A single center experience

Nowadays, an increasing number of neonatal and pediatric patients with severe heart failure benefits from extracorporeal membrane oxygenation (ECMO) support. A total of 39 pediatric patients needed venoarterial ECMO (vaECMO) support in our department between January 2008 and December 2016. Patients were retrospectively divided in two groups: 30‐day survivor group (17 patients) and 30‐day nonsurvivor group (22 patients). Outcome and factors predictive for 30‐day mortality and mid‐ as well as long‐term survival up to 7‐year follow‐up were analyzed by univariate analysis and Kaplan‐Meier survival estimation. Basic demographics and preoperative characteristics did not differ between groups (P > 0.05). 67% of patients were successfully weaned off ECMO and 44% survived 30‐day after ECMO application. After 7‐year follow‐up 28% of pediatric patients were alive. Thirty‐day survivors were significantly more likely to undergo elective cardiac surgery (P = 0.001), whereas significantly more 30‐day nonsurvivors underwent urgent surgery (P = 0.004). Odds of incidence of catecholamine refractory circulatory failure, failed myocardial recovery, and cerebral edema was significantly higher in 30‐day nonsurvivor group (41.6‐fold, 16‐fold, and 2.5‐fold, respectively). Kaplan‐Meier survival estimation analysis revealed significant differences in terms of mid‐ and long‐term survival among neonates, infants, toddlers, and preadolescents (Breslow P = 0.037 and Log‐Rank P = 0.028, respectively). vaECMO provides an efficient therapy option for life‐threatening heart disorders in neonates and pediatric patients being at high risk for myocardial failure leading to circulatory arrest. Urgency of surgery effected on higher mortality, but there was no difference in terms of mortality in 30‐day survivor group in comparison to 30‐day nonsurvivor group among neonates, infants, toddlers, and preadolescents.     

First pediatric HeartMate 3 implantation: US experience

Children with heart failure have few mechanical circulatory support options and have a high incidence of embolic events. The favorable hemocompatibility and smaller profile of HeartMate 3 may provide more long‐term options for the pediatric population.     

Intraoperative glycemic control without insulin infusion during pediatric cardiac surgery for congenital heart disease

Background: Many studies are reporting that the occurrence of hyperglycemia in the postoperative period is associated with increased morbidity and mortality rates in children after cardiac surgery for congenital heart disease. This study sought to determine blood glucose levels in standard pediatric cardiac anesthesiological management without insulin infusions. Methods: The study population consisted of 204 consecutive pediatric patients aged from 3 days to 15.4 years undergoing open cardiac surgery for congenital heart disease between June 2007 and January 2009. Glucose‐containing fluids were not administrated intraoperatively, and all patients received high dose of opioids (sufentanil 10 mcg·kg^?1) and steroids (30 mg·kg^?1 methylprednisolone) iv. Glucose levels were measured before CPB, 10 min after initiation of CPB, every hour on CPB, post–CPB, and on arrival at intensive care unit (ICU). Results: Intraoperatively, only one patient had a glucose level <50 mg·dl^?1 (=34.2 mg·dl^?1), 57/204 patients (27.9%) had at least one intraoperative glucose >180 mg·dl^?1, but only 12 patients (5.8%) had a glucose level >180 mg·dl^?1 at ICU arrival. Thirty‐day mortality was 1.5% (3/204). Younger age, lower body weight, and lower CPB temperature were associated with hyperglycemia at ICU arrival, as were higher RACHS and Aristotle severity scores. Conclusion: A conventional (no insulin, no glucose) anesthetic management seems sufficient in the vast majority of patients (96.5%). Special attention should be paid to small neonates with complex congenital heart surgery, in whom insulin treatment may be contemplated.     

Anesthetic considerations for the pediatric oncology patient – part 2: systems‐based approach to anesthesia

One of the prices paid for chemo‐ and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three‐part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems‐based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.     

Pediatric heart transplantation: demographics, outcomes, and anesthetic implications

The evolving demographics, outcomes, and anesthetic management of pediatric heart transplant recipients are reviewed. As survival continues to improve, an increasing number of these patients will present to our operating rooms and sedation suites. It is therefore important that all anesthesiologists, not only those specialized in cardiac anesthesia, have a basic understanding of the physiologic changes in the transplanted heart and the anesthetic implications thereof.     

Glycopyrrolate during sevoflurane-remifentanil-based anaesthesia for cardiac catheterization of children with congenital heart disease

Background. Remifentanil is recommended for use in procedureswith painful intraoperative stimuli but minimal postoperativepain. However, bradycardia and hypotension are known side-effects.We evaluated haemodynamic effects of i.v. glycopyrrolate duringremifentanil–sevoflurane anaesthesia for cardiac catheterizationof children with congenital heart disease. Methods. Forty-five children undergoing general anaesthesiawith remifentanil and sevoflurane were randomly allocated toreceive either saline, glycopyrrolate 6 µg kg^–1or glycopyrrolate 12 µg kg^–1. After induction ofanaesthesia with sevoflurane, i.v. placebo or glycopyrrolatewas administered. An infusion of remifentanil at the rate of0.15 µg kg^–1min^–1 was started, sevofluranecontinued at 0.6 MAC and cisatracurium 0.2 mg kg^–1 wasgiven. Heart rate (HR) and non-invasive arterial pressures weremonitored and noted every minute for the first 10 min and thenevery 2.5 min for subsequent maximum of 45 min. Results. Baseline HR [mean (SD)] of 117 (20) beats min^–1decreased significantly from 12.5 min onwards after startingthe remifentanil infusion in the control group [106 (18) at12.5 min and 99 (16) beats min^–1 at 45 min]. In the groupsreceiving glycopyrrolate, no significant decrease in HR wasnoticed. Glycopyrrolate at 12 µg kg^–1 induced tachycardiabetween 5 and 9 min after administration. Systolic and diastolicarterial pressures decreased gradually, but there were no significantdifferences in the pressures between groups. Conclusion. I.V. glycopyrrolate 6 µg kg^–1 preventsbradycardia during general anaesthesia with remifentanil andsevoflurane for cardiac catheterization in children with congenitalheart disease. Administering 12 µg kg^–1 of glycopyrrolatetemporarily induces tachycardia and offers no additional advantage.     

Quantitative myocardial tissue characterization by cardiac magnetic resonance in heart transplant patients with suspected cardiac rejection

Distinct histopathologic changes occur in acute cellular rejection (ACR), antibody‐mediated rejection (AMR), and biopsy‐negative rejection (BNR). Cardiovascular magnetic resonance (CMR)‐based myocardial tissue characterization can be used to quantify these changes. We assessed T1, T2, and extracellular volume fraction (ECV) by CMR in patients with subtypes of rejection. T1, T2, and ECV were quantified at the mid‐ventricular level and compared between patients with and without rejection. The association between quantitative tissue characteristics and the combined outcome of death, retransplantation, heart failure hospitalization, or myocardial infarction was evaluated with a Cox‐proportional hazards model. In 46 patients, mean age 53.3 ± 13.7 years, 71.7% male, at a median of 7.4 years from transplant, average myocardial T1 was increased in BNR compared with no rejection (1057 vs 1012 msec, P = .006). Average myocardial T2 was elevated in all types of rejection, P < .05. In a cox‐proportional hazards model, higher T2 values were associated with an increase in the combined clinical outcome (adjusted HR 1.21, 95% CI 1.06‐1.37, P = .004) after adjusting for left ventricular mass index. Myocardial tissue characteristics are abnormal in all subtypes of rejection, and abnormal T2 quantified by CMR provides additional prognostic value.