Stein ML, Staffa SJ, O’Brien Charles A, Callahan R, DiNardo JA, Nasr VG, Brown ML.J Cardiothorac Vasc Anesth. 2022 Jun;36(6):1606-1616. doi: 10.1053/j.jvca.2022.01.014. Epub 2022 Jan 13.PMID: 35181233
Take Home Points:
- Pediatric patients with significant pulmonary hypertension are at high risk for periprocedural adverse events.
- Younger age, longer procedure duration, and location of procedure in the catheterization laboratory were factors independently associated with clinically significant adverse events.
- Periods of airway management or manipulation including induction and emergence from anesthesia are high-risk periods during anesthesia care and should be well-planned and controlled.
Commentary from Dr. Wendy Whiteside (Ann Arbor, MI, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
Patients with pulmonary hypertension (PH) are known to be high risk for periprocedural morbidity and mortality, however procedures are necessary in these patients as serial cardiac catheterizations are often necessary both for diagnostic purposes to guide PH management, as well as therapeutic/interventional cardiac procedures (eg. Intervention on stenotic pulmonary veins) and non-cardiac procedures. In this single center, retrospective cross-sectional study, Stein et al describe their experience at a quaternary-care freestanding children’s hospital in caring for pediatric patients with pulmonary hypertension requiring anesthesia for cardiac catheterization and other non-cardiac procedures. They sought to determine the incidence of clinically significant serious adverse events and factors associated with adverse outcomes in these patients.
Over a 3-year period from 2015-2018, 249 patients underwent 862 procedures (592 for cardiac cath and 278 for non-cardiac surgery and diagnostic imaging). Included patients had significant pulmonary hypertension (PVR >3 iWU, mean PA pressure >25 mmHg, on vasodilator therapy for PH, transpulmonary gradient >6 in univentricular circulation) upon review of data from the index catheterization. Median age was 1.6 years, and weight of 9.5 pounds. The majority of cases were performed with volatile anesthetics (84% of index catheterizations) and a secure airway using endotracheal tube (82% of index catheterizations), with only 9% using a natural airway and 16% IV anesthesia. Nearly half of patients (48%) required initiation of new inotropic support during the case, and 14% required use of inhaled nitric oxide as treatment for PH during the case. 23% of patients newly required ICU care post-catheterization. A quarter of outpatients (11% of all patients) were discharged the same day and an additional 25% were discharged following overnight observation. While for noncardiac surgery/diagnostic imaging procedures, the majority still received volatile/inhaled agents and an endotracheal tube (69% and 59%, respectively), more natural airway (18%) and IV anesthetics (30%) were utilized in these patients. These patients were younger and smaller than the index population, and the majority of procedures took place in the main operating room (66%) with 25% of cases being airway procedures (laryngoscopy, bronchoscopy, tracheostomy, and tonsillectomy).
Clinically significant adverse events occurred in 26% of all encounters (CI 22-30%). The most common events were post-op need for positive pressure ventilation (17% of anesthetic encounters), a new requirement for vasoactive infusion post-operatively (11%), and significant hypoxemia requiring clinical intervention (7%). There were 4 intraoperative cardiac arrests, 3 arrests within 24 hours of anesthetic, and one death within 24 hours of anesthetic. The majority of these intraoperative arrests occurred due to hypoxemia during airway manipulation and the periods of induction and emergence.
Procedures in the cardiac catheterization lab were associated with increased incidence of adverse events compared with other procedures (aOR 5.1; CI 1.7-16, p=0.004) and the OR for clinically significant serious adverse events was 2.23 for interventional catheterizations compared with diagnostic catheterizations (95% CI 1.5-3.3; p<0.001). By multivariable analysis, younger age (aOR 1.4 per year), location in the catheterization lab, and longer procedure duration (aOR 1.3 per 30 minutes; CI 1.1-1.4; p=0.001) were associated with serious adverse events. Patients with tracheostomy in place were less likely to experience an adverse event aOR 0.1; Ci 0.04-0.5;p=0.001) which authors believe is due to these patients generally not requiring airway manipulation. Interestingly, while natural airway and IV anesthetic were relatively protective for adverse events compared with use of endotracheal tube and volatile anesthetics by univariate analysis (OR 0.06, CI 0.02-0.2, p<0.001, and OR 0.5, CI 0.3-0.9, p=0.02, respectively), this association did not remain significant in the multivariate model. Preoperative echo findings were not well associated with risk of adverse events, with only moderate/severe RV dysfunction by echo showing a borderline significance (aOR 3.4, CI 1.1-10; p=0.03).
While these high rates of adverse events are not surprising, it is interesting to see data associated with airway type and anesthetic management. The discussion of whether it is safer to avoid general anesthesia or to utilize general anesthesia and a controlled airway in these patients is a good one. This study did not show a relationship to anesthetic/airway type and adverse events by multivariate analysis, however what is best at a particular center is likely center dependent and primary goal should be in maintaining oxygenation and adequate ventilation throughout the case. The authors state, it is crucially important, that a multidisciplinary team and preplanning are absolutely necessary in caring for these patients. There should be a well thought out plan for induction and extubation and all attempts to minimize anesthesia time in young children with PH should be undertaken.
