Fast-track extubation after modified Fontan procedure

Mutsuga, Masato; Quiñonez, Luis G.; Mackie, Andrew S.; Norris, Colleen M.; Marchak, B. Elaine; Rutledge, John; Rebeyka, Ivan M.

doi:10.1016/j.jtcvs.2012.05.047

Cited by 33 publications

(26 citation statements)

References 12 publications

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“…Traditionally, management of patients recovering from the Fontan procedure has been focused on optimizing cardiac output by volume expansion, minimizing intrathoracic pressure, maintaining low-normal systemic vascular resistance, and enhancing contractility. [20][21][22] The results of this study additionally suggest a potential role for the tailoring of inotropic management, to support renal perfusion pressure in the early postoperative period. One may hypothesize, for example, that reduction in milrinone dose and/or addition of a pure vasoconstrictor might increase MAP while decreasing inotrope score, and thereby potentially reduce the risk of AKI.…”

Section: Discussionmentioning

confidence: 69%

Acute kidney injury after Fontan completion: Risk factors and outcomes

Esch

Salvin

Thiagarajan

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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Objective: Acute kidney injury (AKI) is a predictor of outcomes in heterogeneous populations of children undergoing cardiac surgery. We investigated its causes and consequences in a cohort undergoing Fontan completion, hypothesizing that central venous pressure is independently associated with development of AKI.Methods: In this retrospective cohort study of patients undergoing Fontan (n ¼ 211), univariable and multivariable analyses identified factors associated with AKI within 3 days of surgery. Secondary analyses identified factors associated with hospital length of stay, and examined effects of perioperative kidney injury on follow-up renal function.Results: Acute kidney injury occurred in 42% of cases (n ¼ 89), with the following independent risk factors: mean renal perfusion (mean arterial minus central venous) pressure on postoperative day zero (per mm Hg; adjusted odds ratio [AOR] 0.83; P < .001); preoperative atrioventricular valve regurgitation > mild (AOR 6.78; P ¼ .02); bypass time (per 10 minutes, AOR 1.08; P ¼ .04); peak inotrope score on postoperative day zero (per point, AOR 1.17; P < .001); and preoperative pulmonary vascular resistance (per Wood unit, AOR 1.69; P ¼ .04). Central venous pressure was not independently associated with AKI. Moderate and severe (but not mild) AKI were independently associated with prolonged hospital length of stay (adjusted hazard ratios, 0.56; P ¼ .004, and .41; P ¼ .006, respectively). Perioperative injury was not associated with longer-term renal dysfunction.Conclusions: Acute kidney injury is common after Fontan completion and has several potentially modifiable risk factors. Moderate-to-severe injury is associated with longer hospital length of stay but not with renal dysfunction at follow-up. (J Thorac Cardiovasc Surg 2015;150:190-7) Effect of acute kidney injury on length of stay after Fontan completion. Central MessageAcute kidney injury is common after Fontan completion, and moderate-to-severe AKI predicts longer hospital length of stay. Injury seems to be mediated more by systemic hypotension than by central venous hypertension. Maintaining postoperative renal perfusion pressure while moderating inotrope use might reduce risk of injury and thus length of stay. PerspectiveAcute kidney injury in adults undergoing cardiac surgery is strongly associated with adverse outcomes. The importance of cardiac surgery-associated AKI in children is less clear. Patients undergoing Fontan completion face an acute rise in renal venous pressure and thus comprise an appealing model population. Acute kidney injury is common after the Fontan procedure, and moderate-to-severe AKI predicts longer hospital length of stay. Lower renal perfusion pressure and higher peak inotrope score are independent risk factors for AKI, whereas higher central venous pressure is not. This study provides important insight on the pathophysiology of AKI, and suggests strategies to mitigate AKI in this population.

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Section: Discussionmentioning

confidence: 69%

Acute kidney injury after Fontan completion: Risk factors and outcomes

Esch

Salvin

Thiagarajan

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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“…The median amount of first day pleural and peritoneal effusions was 78.8 mL kg −1 day −1 . The median time for the removal of drains did not differ significantly between the sildenafil and control groups (11 [8][9][10][11][12][13][14][15][16][17][18][19] vs 11 [7][8][9][10][11][12][13][14][15][16] d, respectively, P = .532). The relative amount of pleural and peritoneal effusions on the first POD and the length of stay in the PICU and hospital was also similar ( Table 2).…”

Section: Re Sultsmentioning

confidence: 99%

“…[11][12][13] Early extubation after the TCPC procedure has been associated with improved hemodynamics and shorter time for the chest tube removal as the negative inspiratory intrathoracic pressure enhances pulmonary venous in return. 14,15 In the study by Giordano Intravenous sildenafil reduced the pulmonary artery pressure by about 10% in infants undergoing cardiac surgery with slightly elevated pulmonary artery pressures. 16 Also, sildenafil significantly reduced the systemic blood pressure with systemic vasodilatation and deterioration in oxygenation, which was not improved by the administration of iNO.…”

Section: Re Sultsmentioning

confidence: 99%

The effect of sildenafil on pleural and peritoneal effusions after the TCPC operation

Koski

Suominen

Raissadati

et al. 2019

Acta Anaesthesiol Scand

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The total cavopulmonary connection (TCPC) operation is the last stage in the palliative treatment of patients with a univentricular heart malformation. Prolonged pleural and peritoneal effusions, however, remain as a significant source of morbidity after the TCPC operation. 1,2 The high pre-operative pulmonary artery pressure is a risk factor for prolonged pleural effusion. 3 Sildenafil has been used in the treatment of pulmonary hypertension. Sildenafil reduces pulmonary vascular resistance and the transpulmonary gradient, which could, in theory, decreases pleural and peritoneal effusions after the TCPC operation. 4 Therefore, in 2006, our institution started the administration of sildenafil after the TCPC operation for occasional patients and usually later than 24 hours after the operation, and since 2009, the majority of the patients received their first dose of sildenafil pre-operatively in the morning of the operation.However, the benefits of sildenafil have been controversial in the two recent retrospective Fontan series. 5,6 Our aim in this study was to analyze the effect of prophylactic sildenafil on pleural and peritoneal effusions during the first post-operative day (POD) after the TCPC surgery. We hypothesized that the

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“…in the operating suite or shortly after arrival to the intensive care unit) relatively common in pediatric cardiac surgery [1][2][3]. Many children however, particularly neonates, continue to require mechanical ventilator support for several days or even weeks postoperatively [4][5].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

Laudato

Gupta

Walters

et al. 2015

Pediatric Critical Care Medicine

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Objective: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, though data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. Design: Retrospective chart reviewSetting: Urban tertiary care free-standing children's hospital Interventions: Extubation failure was defined as re-intubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. Measurements & Main Conclusions:Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.3

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Fast-track extubation after modified Fontan procedure

Abstract: Extubation in the operating room after a modified Fontan procedure seems feasible. This approach is associated with improved early postoperative hemodynamics, earlier time to chest tube removal, and shorter intensive care unit and hospital lengths of stay.

Cited by 33 publications

References 12 publications

Acute kidney injury after Fontan completion: Risk factors and outcomes

Acute kidney injury after Fontan completion: Risk factors and outcomes

The effect of sildenafil on pleural and peritoneal effusions after the TCPC operation

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

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