Ingrid Hollinger

New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room

RECENTLY, the New York State (NYS) Department of Health sought the help of physicians after the intraoperative death of a 4-yr-old child was attributed to application of topical phenylephrine by the treating practitioners. A panel consisting of anesthesiologists, otorhinolaryngologists, intensivists, and pharmacists joined state authorities in reviewing this case to determine whether topical phenylephrine use in surgery could be an underrecognized source of morbidity. On March 10,1998, the Commissioner of Health in NYS accepted the recommendations of this panel and circulated a letter to all hospital administrators in the state, establishing guidelines for the use of phenylephrine in the operating room. It is important for all anesthesiologists to be aware of the clinical problems associated with topical vasoconstrictors that led to the development of these guidelines.

Factors Affecting the Decision to Defer Endotracheal Extubation After Surgery for Congenital Heart Disease: A Prospective Observational Study

BACKGROUND: Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR). METHODS: We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites. RESULTS: Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria. CONCLUSIONS: Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.

Comparison of cisatracurium and vecuronium by infusion in neonates and small infants after congenital heart surgery.

Background:Neonates and infants often require extended periods of mechanical ventilation facilitated by sedation and neuromuscular blockade. Methods:Twenty-three patients aged younger than 2 yr were randomly assigned to receive either cisatracurium or vecuronium infusions postoperatively in a double-blinded fashion after undergoing congenital heart surgery. The infusion was titrated to maintain one twitch of a train-of-four. The times to full spontaneous recovery of train-of-four without fade, extubation, intensive care unit discharge, and hospital discharge were documented after drug discontinuation. Sparse sampling after termination of the infusion and a one-compartment model were used for pharmacokinetic analysis. The Mann-Whitney U test and Student t test were used to compare data between groups. Results:There were no significant differences between groups with respect to demographic data or duration of postoperative neuromuscular blockade infusion. The median recovery time for train-of-four for cisatracurium (30 min) was less than that for vecuronium (180 min) (P < 0.05). Three patients in the vecuronium group had prolonged train-of-four recovery: Two had long elimination half-lives for vecuronium, and one had a high concentration of 3-OH vecuronium. There were no differences in extubation times, intensive care unit stays, or hospital stays between groups. Conclusions:Our results parallel data from adults demonstrating a markedly shorter recovery of neuromuscular transmission after cisatracurium compared with vecuronium. Decreased clearance of vecuronium and the accumulation of 3-OH vecuronium may contribute to prolonged spontaneous recovery times. Cisatracurium is associated with faster spontaneous recovery of neuromuscular function compared with vecuronium but not with any differences in intermediate outcome measures in neonates and infants.

Cardiac catheterization laboratory: catheterization, interventional cardiology, and ablation techniques for children.

Cardiac catheterization as a diagnostic tool was first described in 1947. In 1958, Smith reported on the anesthetic experience with a sedative (lytic) cocktail, the widely used and traditional mixture of meperidine, promethazine, and chlorpromazine (DPT). The goal for sedation for cardiac catheterization was and is to achieve a cooperative patient with minimal interference with hemodynamic parameters. The data collected should be as close to normal as possible. With the advancements in noninvasive diagnostics in pediatric cardiology, particularly echocardiography, pure acquisition of anatomic and/or physiologic data is becoming less common. The main emphasis of pediatric cardiac catheterization is shifting toward therapeutic, transcatheter interventions. The latter frequently necessitates general anesthesia to prevent accidental patient movement.

Recognition of a cleft mitral valve utilizing real-time three-dimensional transoesophageal echocardiography

We present a case in which real-time three-dimensional transoesophageal echocardiography was utilized to obtain better understanding of a cleft mitral valve. Additionally, the embryological development of a cleft mitral valve will be reiterated.

Continuous positive airway pressure and lung separation during cardiopulmonary bypass to facilitate congenital heart surgery via the right thorax in children.

We describe a fast track anesthesia technique that facilitates congenital heart surgery via right axillary thoracotomy in children. Continuous positive airway pressure on the dependent lung, before and during cardiopulmonary bypass, approximates the heart towards the chest wall incision, and significantly improves the surgeons access to the heart.

Repair of an Aortic Sinus Right Ventricular Fistula and Aortic Leaflet Disruption After a Stab Wound

A28-year-old man with no significant past medical history presented to an outside hospital after a stab wound to the right anterior chest. The patient underwent an emergent median sternotomy to treat tamponade from a perforated right ventricle. A primary repair of the ventricle was performed, chest tubes were placed, and the patient’s chest was closed. Postoperatively, while still at the outside hospital, transesophageal echocardiography demonstrated a presumably traumatic fistula from the right sinus of Valsalva to the right ventricle with a gradient of 50 mm Hg, and moderate aortic insufficiency (Fig 1). Additionally, a soft, continuous murmur was present in the right parasternal area. The patient was transferred for definitive surgery. A resternotomy was performed and aortobicaval bypass commenced. An oblique aortotomy revealed a 1 cm laceration at the base of the right sinus of Valsalva approximately 0.5 cm to the left of the right coronary ostium (Fig 2A, black arrow). Directly opposite this was an 8 mm laceration in the right aortic cusp (Fig 2B, black arrow) and a 2 to 3 mm laceration in the left aortic cusp (Fig 2C). There did not appear to be any injury to the left coronary sinus. Primary repair of the right sinus of Valsalva was performed with a double layer 6-0 Prolene, and the lacerations in both the right and left valve leaflets

Early Extubation in Adults Undergoing Surgery for Congenital Heart Disease

OBJECTIVES Early extubation in adults undergoing surgery for congenital heart disease has not been described. The authors report their experience with extubation in the operating room (OR), including factors associated with the decision to defer extubation to a later time. DESIGN A retrospective chart review. SETTING A tertiary-care teaching hospital. PARTICIPANTS This study included adults undergoing surgery for congenital heart disease using cardiopulmonary bypass. Exclusion criteria were as follows: preoperative mechanical ventilation, age >70 years, inotrope score >20 after surgery, and surgical risk (Risk Adjustment for Congenital Heart Surgery [RACHS] score ≥4). INTERVENTIONS A stepwise logistic regression model was used to test for the independent influence of the various factors on extubation in the OR. MEASUREMENTS AND MAIN RESULTS Sixty-seven patients (age 18-59 years, median = 32 years) were included. Overall, 79% of patients were extubated in the OR. The RACHS score was the strongest predictor of deferring extubation (RACHS 3 v 1 or 2: odds ratio = 16.7; 95% confidence interval, 3.3-84.2; p = 0.0006). Further exploration of the high-risk group (RACHS 3) showed that 75% of the RACHS 3 patients with a body mass index <25 were extubated compared with only 20% of patients who had a body mass index ≥25 (p = 0.01). Other factors included in the analysis did not contribute any additional independent information. CONCLUSIONS Extubation of adult patients in the OR after surgery for congenital heart disease is feasible in most cases. Surgical risk (RACHS score) and body mass index predict the decision for OR extubation in this patient population.