A National Survey: Current Clinical Practice in Pediatric Anesthesia for Congenital Heart Surgery

Abstract

Background: Providing anesthesia for pediatric patients undergoing congenital cardiac surgery is complex and requires profound knowledge and clinical experience. Prospective studies on best anesthetic management are missing, partially due to different standards. The aim of the present study was to survey the current standard practice in anesthetic management in pediatric cardiac surgical centers in Germany. Methods: All 78 cardiac surgical centers in Germany were reviewed for a congenital cardiac surgery program. Centers with an active program for congenital cardiac surgery were interviewed to participate in the present online questionnaire to assess their current anesthetic practice. Results: Twenty-seven German centers running an active program for congenital heart surgery were identified, covering more than 3,000 pediatric cardiac surgeries annually. Of these centers, 96.3% (26/27) participated in our survey. Standard induction agents were etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26). General anesthesia was preferentially maintained using volatile agents, 61.5% (16/26), with sevoflurane being the most common volatile agent within this group, 81.2% (13/16). Intraoperative first-choice/first-line inotropic drug was epinephrine, 53.8% (14/26), followed by milrinone, 23.1% (6/26), and dobutamine 15.4% (4/26). Fast-track programs performing on-table extubation depending on the type of surgical procedure were established at 61.5% (16/26) of the centers. Conclusion: This study highlights the diversity of clinical standards in pediatric cardiac anesthesia for congenital cardiac surgery in Germany.

Sedation versus General Anesthesia for Cardiac Catheterization in Infants: A Retrospective, Monocentric, Cohort Evaluation

“…There is a wide variability of anesthetic techniques used in the catheterization laboratory (various uses of sedation or GA, various professionals for sedation management [ 18 ], and lastly, various medications [ 19 ]). During cardiac catheterization in children, both anesthesiologists and cardiologists need to be aware of hemodynamic effects of anesthetic agents, as those can influence hemodynamic calculations that are crucial for decision-making for congenital heart diseases.…”

Point-of-Care Ultrasound-Guided Protocol to Confirm Central Venous Catheter Placement in Pediatric Patients Undergoing Cardiothoracic Surgery: A Prospective Feasibility Study

“…However, during high-risk procedures, such as congenital cardiac or major pediatric surgeries, multilumen CVC with larger diameters, analogous to those used in adult perioperative medicine, are required to perform differentiated drug therapies and perfuse higher volumes. While various central veins are feasible to access, the most common puncture site for CVC in pediatric anesthesia for congenital heart surgery in Germany is the internal jugular vein [1]. Point-of-care verification of CVC positioning is not standardized in pediatric patients and correct positioning is usually verified postoperatively by X-ray [2].…”

“…Central venous puncture is nowadays ultrasound guided at the majority of pediatric heart centers [1]. However, existing formulas calculating depth of insertion based on body dimensions are unreliable, especially in children with pathologic heart dimensions or abnormal anatomy [6].…”

Low-body-perfusion via an arterial sheath reduces inflammation after aortic arch reconstruction surgery

“…2,5 Anesthesia management and cardiopulmonary bypass (CPB) techniques during congenital cardiac surgeries differ between institutions to a significant extent. 6 With increases in pathophysiological knowledge and technological development in extracorporeal circulation (ECC), more sophisticated perfusion strategies and procedures have been developed, resulting in improved perioperative outcomes in this special group of patients. [7][8][9][10] Hereby, surgeries requiring deep hypothermic circulatory arrest (DHCA) have mostly disappeared, apart from procedures involving reconstruction of the aorta.…”

“…Various selective perfusion techniques have been developed to prevent the deleterious consequences of DHCA-associated hypoperfusion including selective antegrade cerebral perfusion (ACP) in order to improve neurological outcomes. [5][6][7][8][9] In addition to brain protection, ACP has been shown to decrease lactate levels, reduce the need for inotropic support and intensive care therapy, and prevent acute postoperative kidney injury after pediatric cardiac surgeries requiring DHCA. [11][12][13][14] Hypothermia, inflammation, decreased renal and non-pulsatile blood flow are all present during CPB and may cause acute kidney injury (AKI), a common complication after pediatric cardiac surgery.…”