David F. Vener

Dimenhydrinate Decreases Vomiting After Strabismus Surgery in Children

Dimenhydrinate, a H1-receptor antagonist, has been used to both prevent and treat postoperative vomiting (POV) in children for several decades. However, its effectiveness for POV after strabismus surgery remains anecdotal. This study was designed to determine the effectiveness and side effects of dimenhydrinate for the prevention of POV in children after strabismus surgery. Eighty ASA physical status I or II children, ages 1-12 yr inclusive, who were undergoing strabismus surgery, were prospectively and randomly allocated to receive either dimenhydrinate 0.5 mg/kg intravenously (n = 40) or placebo (n = 40) at induction of anesthesia. The incidence of POV and the times to arousal and discharge from the recovery room and hospital were recorded postoperatively in a double-blinded manner. For 24 h after discharge from the hospital, all emetic episodes and medications given were recorded by the parents. Demographic data did not differ between the groups. Children who received dimenhydrinate had significantly less POV both inhospital (10%) and overall (30%) than those who received placebo (in-hospital 38%, P < 0.008; overall 65%, P < 0.003). The times to arousal and discharge from the hospital did not differ between the two groups. Dimenhydrinate (0.5 mg/kg) is an effective, safe, and inexpensive antiemetic in children undergoing strabismus surgery. It significantly reduces the incidence of vomiting for 24 h postoperatively and is not associated with prolonged sedation or other adverse effects. (Anesth Analg 1996;82:728-31)

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Research

The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It contains data pertaining to more than 435,000 total operations. The most recent biannual feedback report to participants (Spring 2017, Report of the Twenty-Sixth Harvest) included analysis of data submitted from 127 hospitals in North America. That represents nearly all centers performing pediatric and congenital heart operations in the United States and Canada. As an unparalleled platform for assessment of outcomes and for quality improvement activities in the subspecialty of surgery for pediatric and congenital heart disease, the STS CHSD continues to be a primary data source for clinical investigations and for research and innovations related to quality measurement. In 2016, several major original publications reported analyses of data in the CHSD pertaining to various processes of care, including assessment of variation across centers and associations between specific practices, patient characteristics, and outcomes. Additional publications reported the most recent development, evaluation, and application of metrics for quality measurement and reporting of pediatric and congenital heart operation outcomes and center level performance. Use of the STS CHSD for outcomes research and for quality measurement continues to expand as database participation has grown to include nearly all centers in North America, and the available wealth of data in the database continues to grow. This article reviews outcomes research and quality improvement articles published in 2016 that are based on STS CHSD data.

Clinical Databases and Registries in Congenital and Pediatric Cardiac Surgery, Cardiology, Critical Care, and Anesthesiology Worldwide:

The growth in large-scale data management capabilities and the successful care of patients with congenital heart defects have coincidentally paralleled each other for the last three decades, and participation in multicenter congenital heart disease databases and registries is now a fundamental component of cardiac care. This manuscript attempts for the first time to consolidate in one location all of the relevant databases worldwide, including target populations, specialties, Web sites, and participation information. Since at least 1,992 cardiac surgeons and cardiologists began leveraging this burgeoning technology to create multi-institutional data collections addressing a variety of specialties within this field. Pediatric heart diseases are particularly well suited to this methodology because each individual care location has access to only a relatively limited number of diagnoses and procedures in any given calendar year. Combining multiple institutions data therefore allows for a far more accurate contemporaneous assessment of treatment modalities and adverse outcomes. Additionally, the data can be used to develop outcome benchmarks by which individual institutions can measure their progress against the field as a whole and focus quality improvement efforts in a more directed fashion, and there is increasing utilization combining clinical research efforts within existing data structures. Efforts are ongoing to support better collaboration and integration across data sets, to improve efficiency, further the utility of the data collection infrastructure and information collected, and to enhance return on investment for participating institutions.

Upper body central venous catheters in pediatric cardiac surgery.

A central venous catheter located in the jugular or subclavian vein provides rapid, reliable vascular access for pediatric heart surgery. However, intravascular catheters are associated with vessel injury. Stenosis or thrombosis of central veins in the upper body can lead to ‘superior vena cava syndrome’ with markedly elevated venous pressures in the head and neck, causing facial swelling and headaches. This complication may be especially serious for patients with superior cavopulmonary (Glenn) or total cavopulmonary (Fontan) circulation. The authors hypothesized that upper body central line placement would be associated with a low risk of venous thrombosis or stenosis.

International quality improvement initiatives

Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.

Anesthesia and Databases: Pediatric Cardiac Disease as a Role Model.

Large data sets have now become ubiquitous in clinical medicine; they are particularly useful in high-acuity, low-volume conditions such as congenital heart disease where data must be collected from many centers. These data fall into 2 categories: administrative data arising from hospital admissions and charges and clinical data relating to specific diseases or procedures. In congenital cardiac diseases, there are now over a dozen of these data sets or registries focusing on various elements of patient care. Using probabilistic statistic matching, it is possible to marry administrative and clinical data post hoc using common elements to determine valuable information about care patterns, outcomes, and costs. These data sets can also be used in a collaborative fashion between institutions to drive quality improvement (QI). Because these data may include protected health information (PHI), care must be taken to adhere to federal guidelines on their use. A fundamental principle of large data management is the use of a common language and definition (nomenclature) to be effective. In addition, research derived from these information sources must be appropriately balanced to ensure that risk adjustments for preoperative and surgical factors are taken into consideration during the analysis. Care of patients with cardiac disease both in the United States and abroad consistently shows wide variability in mortality, morbidity, and costs, and there has been a tremendous amount of discussion about the benefits of regionalization of care based on center volume and outcome measurements. In the absence of regionalization, collaborative learning techniques have consistently been shown to minimize this variability and improve care at all centers, but before changes can be made it is necessary to accurately measure accurately current patient outcomes. Outcomes measurement generally falls under hospital-based QI initiatives, but more detailed analysis and research require Institutional Review Board and administrative oversight. Cardiac anesthesia providers for these patients have partnered with the Society of Thoracic Surgeons Congenital Heart surgeons to include anesthesia elements to help in this process.

Anesthetic Considerations for Adults Undergoing Fontan Conversion Surgery

There are currently in North America more adults with congenital heart disease than children. This article discusses the anesthetic considerations in adults with single-ventricle physiology and prior repairs who present for Fontan conversion surgery as a demonstration of the challenges of caring for adults undergoing interventions for the repair of congenital heart defects. The care of these patients requires an understanding of the impact of passive pulmonary blood flow and single systemic ventricular physiology. The perioperative morbidity in this patient population remains high.

Databases and outcomes in congenital cardiac anesthesia.

Anesthesia practitioners have long been at the forefront of patient safety initiatives in the operating room and beyond. The Congenital Cardiac Anesthesia Society has partnered with the Society of Thoracic Surgeons Congenital Heart Surgery Database to develop a patient registry for patients with congenital heart defects in order to determine patient outcomes related to anesthesia in this high-risk population. A review of existing database efforts is also undertaken to determine their strengths and weaknesses.

Another Way to Skin a Cat (Apologies to the SPCA and PETA)

Early extubation after congenital heart surgery in neonates, infants, and children is not a new idea. Barash et al published their experiences with 197 consecutive patients in the “modern” era of congenital heart surgery in 1980, half of whom were less than three years of age and 30% were less than one year of age. A total of 57% of these cases were performed under cardiopulmonary bypass. Considering the limitations of anesthetic agents at the time (largely pancuronium, halothane, and morphine), they achieved a remarkable 72% extubation rate either in the operating room or shortly after arrival in the intensive care unit (ICU) with a 4% reintubation rate. In this month’s World Journal, Shinkawa et al present their experience with 909 potential candidates for immediate extubation over a five-year period from 2011 to 2016 at their hospital, of whom 590 (65%) were extubated in the OR. It is likely that their hospital’s anesthesia group reflects a heterogeneity of practice that is found at many centers around the country, and their manuscript does not reflect any standardized anesthetic protocols to achieve the goal of extubation. Within their stable group of nine anesthesiologists, there are “early extubation” champions, including their chairman, and those who were initially less comfortable with this change. Not surprisingly, the anesthesiologist’s identity was one of several factors found post hoc to have influenced the decision to extubate. However, over time and with greater experience, they saw a marked overall increase in the number of patients successfully extubated in the operating room. Other factors found to significantly contribute to early extubation success included patient age and weight, case complexity (STAT Score), CPB time, aortic cross-clamp time, and lowest core temperature—all variables that have been shown to be consistent in many other manuscripts related to this topic. There is no precise definition of early extubation. Publications have referred to it as extubation of the trachea postsurgery from as early as intraoperatively at the conclusion of surgery prior to transport to the ICU to as late as 24 hours after departure from the operating room. If there is a consensus, it appears that most anesthesiologists would refer to very early extubation or immediate extubation as that occurring in the operating room or upon arrival in the ICU prior to connecting to an ICU ventilator and early extubation as that occurring within six hours of arrival in the ICU. The potential benefits of early extubation are extensive: less barotrauma with positive pressure ventilation and tracheal irritation, avoidance of accidental and/or unrecognized extubation, less sedative and analgesic requirements, earlier assessment of a patient’s neurologic status, decreased risk of endotracheal tube obstruction by either kinking or plugging, less risk of triggering of a pulmonary hypertensive crisis with manipulation or suctioning and potentially less need for vasoactive agents to counteract the effects of sedatives and narcotics, and the benefit to the family of being able to communicate and reassure (and be reassured by) their child. Spontaneous ventilation has also been shown to be beneficial particularly in patients undergoing total cavopulmonary connection surgery. I don’t think the emotional benefit to worried families can be underestimated to see their child arousable and conversant in the early postoperative period after open heart surgery. Anecdotally, I have had many patients and their families tell me that the most distressing part of the perioperative experience is being awake with an endotracheal tube in place even with adequate analgesia. There are cogent arguments against early extubation. These have centered around the beneficial effects of deeper anesthetic depth and a blunting of the stress response intraoperatively through high-dose narcotic techniques and better management of ventilatory settings, including the application of PEEP to minimize atelectasis as well as avoiding the need to reintubate for either failed initial attempts to extubate or due to conditions

National Benchmarks for Proportions of Patients Receiving Blood Transfusions During Pediatric and Congenital Heart Surgery: An Analysis of the STS Congenital Heart Surgery Database

BACKGROUND To determine national benchmarks and assess variability across centers, The Society of Thoracic Surgeons Congenital Heart Surgery Database was analyzed to document proportions of patients receiving intraoperative transfusion of packed red blood cells (PRBC) during open heart surgery. METHODS Index cardiopulmonary bypass operations reported in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2014 to 2015) were potentially eligible for inclusion. Data from centers with more than 15% missing data for PRBC transfusion were excluded, as were individual records missing information about PRBC transfusion. The distribution of center-level PRBC transfusion rates in various clinically relevant groups was estimated by fitting a two-level logistic mixed model. RESULTS The study population included 22,874 index cardiopulmonary bypass operations in 81 centers. Center-level intraoperative PRBC transfusion rates stratified by age group, weight, STAT Mortality Category, and lowest core temperature were documented. For younger patients and patients undergoing higher-complexity operations, median center PRBC transfusion rates consistently approached 100%, with narrow interquartile ranges indicating little center variability. Center PRBC transfusion rates declined with increasing patient age, but with greater variability (wider interquartile ranges) across centers. Intraoperative PRBC transfusion was uncommon (median center transfusion rates <30%) in older patients (teenagers and adults) undergoing lower-complexity (STAT Mortality Category <3) operations. CONCLUSIONS Most centers transfuse PRBCs routinely in higher-risk, younger, and smaller patients, with little variability across centers. For lower-risk operations in older and larger patients, centers are more likely to forgo intraoperative transfusions. This analysis provides national benchmarks for center-level PRBC transfusion rates during pediatric and congenital heart surgery.