Incidence of Peri-anesthetic Adverse Events in Children with

Congenital Cardiac Defects Undergoing Procedures in the Cardiac Catherization

Laboratory Requiring Anesthesia.

Incidence of Peri-anesthetic Adverse Events in Children with

Congenital Cardiac Defects Undergoing Procedures in the Cardiac Catherization

Laboratory Requiring Anesthesia.

R.P. Moore M.D.; A. Kakavouli M.D.; M. Carson R.N.; S. Ohkawa M.D. ; L.S. Sun M.D.Columbia University Department of

AnesthesiologyNew York, NY

R.P. Moore M.D.; A. Kakavouli M.D.; M. Carson R.N.; S. Ohkawa M.D. ; L.S. Sun M.D.Columbia University Department of

AnesthesiologyNew York, NY

IntroductionIntroduction

Inpatients with a history of congenital heart disease (CHD) are at increased risk for mortality following non-cardiac surgery (1).

Therefore, CHD patients are presumably at high risk for

morbidity and mortality for all non-cardiac procedures (2).

This risk may be increased by the physiologic manipulations that occur in the cardiac catherization laboratory (Cath Lab)

This study quantifies the incidence of peri-anesthetic adverse events (AE) in CHD patients undergoing Cath Lab procedures requiring anesthesia care at our institution.

Inpatients with a history of congenital heart disease (CHD) are at increased risk for mortality following non-cardiac surgery (1).

Therefore, CHD patients are presumably at high risk for

morbidity and mortality for all non-cardiac procedures (2).

This risk may be increased by the physiologic manipulations that occur in the cardiac catherization laboratory (Cath Lab)

This study quantifies the incidence of peri-anesthetic adverse events (AE) in CHD patients undergoing Cath Lab procedures requiring anesthesia care at our institution.

MethodsMethods

Following IRB approval, prospective data for all CHD patients undergoing Cath Lab procedures between August and October of 2008 were collected

Patients whose Cath lab procedures were in combination with direct surgical manipulation of the heart were excluded

Patients undergoing Electrophysologic or Pulmonary Hypertension studies were also excluded

Following IRB approval, prospective data for all CHD patients undergoing Cath Lab procedures between August and October of 2008 were collected

Patients whose Cath lab procedures were in combination with direct surgical manipulation of the heart were excluded

Patients undergoing Electrophysologic or Pulmonary Hypertension studies were also excluded

MethodsMethods Data pertaining to demographics, biometrics, medical history,

anesthesia care, procedure type, disposition, and outcome were collected.

Primary outcomes were Adverse Events (AE) as defined by institutional protocol and included death or end-organ dysfunction occurring within the first 72 postoperative hours.

Secondary outcomes were alterations in planned care.

Data were analyzed by unpaired t test or Chi-square as appropriate. P<0.05 was deemed significant.

Data pertaining to demographics, biometrics, medical history, anesthesia care, procedure type, disposition, and outcome were collected.

Primary outcomes were Adverse Events (AE) as defined by institutional protocol and included death or end-organ dysfunction occurring within the first 72 postoperative hours.

Secondary outcomes were alterations in planned care.

Data were analyzed by unpaired t test or Chi-square as appropriate. P<0.05 was deemed significant.

Results:Results:

Data were collected for 88 CHD patients undergoing procedures in the Cath Lab that required anesthesia care

Data Were collected for patients with diverse diagnoses, biometrics, and disease burden

Data were collected for 88 CHD patients undergoing procedures in the Cath Lab that required anesthesia care

Data Were collected for patients with diverse diagnoses, biometrics, and disease burden

ResultsResults

0

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90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EastWestNorth

Overall Population AEPatients (N) 88 14

ASA 1 to 2 16 2 P=0.93, D=0.623 60 104 12 2

Gender Male 55 9 P=0.89, D=0.34Female 33 5

Age Mean ± SD (months) 55.1 ± 54.8 57.7 ± 56.1 P= 0.87, D=0.38Weight Mean ± SD (KG) 18.1 ± 14.6 21.0 ± 21.5 P=0.62, D= 0.53

Initial RACHS-1 1 to 2 14 4 P=0.71, D= 0.703 to 4 17 35 to 6 26 4

# Cardiac Meds 0 22 4 P=0.89, 1 to 2 42 7 D= 0.64

3+ 24 3Anesthesia Duration Mean ± SD (min) 163 ± 73.8 205.6 ± 58.8 P=0.025,

D=0.98Daignosis Single Ventricle N- 28 N-5

HPLHS-19 HPLHS-2S/P OHT N-26 N-2

DCM-12 HPLHS-2HPLHS-7

TOF 5 1ASD/VSD/AVC 10 2

Overall Population AEPatients (N) 88 14

ASA 1 to 2 16 2 P=0.93, D=0.623 60 104 12 2

Gender Male 55 9 P=0.89, D=0.34Female 33 5

Age Mean ± SD (months) 55.1 ± 54.8 57.7 ± 56.1 P= 0.87, D=0.38Weight Mean ± SD (KG) 18.1 ± 14.6 21.0 ± 21.5 P=0.62, D= 0.53

Initial RACHS-1 1 to 2 14 4 P=0.71, D= 0.703 to 4 17 35 to 6 26 4

# Cardiac Meds 0 22 4 P=0.89, 1 to 2 42 7 D= 0.64

3+ 24 3Anesthesia Duration Mean ± SD (min) 163 ± 73.8 205.6 ± 58.8 P=0.025,

D=0.98Daignosis Single Ventricle N- 28 N-5

HPLHS-19 HPLHS-2S/P OHT N-26 N-2

DCM-12 HPLHS-2HPLHS-7

TOF 5 1ASD/VSD/AVC 10 2Aortic Stenosis 5 2

ResultsResults

14/88 patients (15.9%) undergoing procedures in the CL requiring anesthesia care experienced AE

Institutional QA data reveals an AE rate of 4.2 % for all anesthetized patients.

Institutional QA data reveals an AE rate of 8.2 % for all CHD patients undergoing noncardiac procedures outside the Cath Lab

14/88 patients (15.9%) undergoing procedures in the CL requiring anesthesia care experienced AE

Institutional QA data reveals an AE rate of 4.2 % for all anesthetized patients.

Institutional QA data reveals an AE rate of 8.2 % for all CHD patients undergoing noncardiac procedures outside the Cath Lab

ResultsResults

9/16 Cath Lab Adverse Events Involved Cardiopulmonary disturbances

7 Patients (5 with cardiopulmonary AE required significant escalations of care

Escalations included: 1 day of mechanical ventilation; 1 ward and 4 ICU admissions

9/16 Cath Lab Adverse Events Involved Cardiopulmonary disturbances

7 Patients (5 with cardiopulmonary AE required significant escalations of care

Escalations included: 1 day of mechanical ventilation; 1 ward and 4 ICU admissions

Cardiopulmonary Adverse Events

Cardiopulmonary Adverse Events

LESION AGE- (mos) WEIGHT(kg) Procedure Morbidity commentpda, pulm htn 122.4 50.9 Case Cancelled allergic rxn at induction -case cx - rx with epi 25 mcg, decadron,benadryl to icu- d/c home with predniosne ; also difficult airway

HPLHS- failed norwood - oht 1/08 132.7 31.9 Diagnostic hypotension- 10 mcg epinephrine Aortic stenosis, ? COA 1.9 2.495 Diagnostic Bronchosapsm

Restrcitive cm 45.6 12.9 Diagnostic desaturation- pulm edema - diuresed.TOF 2.6 4.1 Lpa Balloon hypotension- epi infusionTGA 20.6 13.2 RPA stent hypotension - epi 4 mcg given

Shone's complex; COA bicuspid AV 3.4 6.24 Balloon COA Unexplained Tachycardia 220s - stable bp at extubationTOF 44.9 9.71 Diagnostic AV block dec hr with cath - atropine0.1 mg

DILV, COA 3.2 7.2 Diagnostic laryngospam - bradycardia -- compression / epi 22 mcg

LESION AGE- (mos) WEIGHT(kg) Procedure Morbidity commentpda, pulm htn 122.4 50.9 Case Cancelled allergic rxn at induction -case cx - rx with epi 25 mcg, decadron,benadryl to icu- d/c home with predniosne ; also difficult airway

HPLHS- failed norwood - oht 1/08 132.7 31.9 Diagnostic hypotension- 10 mcg epinephrine Aortic stenosis, ? COA 1.9 2.495 Diagnostic Bronchosapsm

Restrcitive cm 45.6 12.9 Diagnostic desaturation- pulm edema - diuresed.TOF 2.6 4.1 Lpa Balloon hypotension- epi infusionTGA 20.6 13.2 RPA stent hypotension - epi 4 mcg given

Shone's complex; COA bicuspid AV 3.4 6.24 Balloon COA Unexplained Tachycardia 220s - stable bp at extubationTOF 44.9 9.71 Diagnostic AV block dec hr with cath - atropine0.1 mg

DILV, COA 3.2 7.2 Diagnostic laryngospam - bradycardia -- compression / epi 22 mcg

DiscussionDiscussion

CHD patients with diverse diagnoses, demographics, and biometrics undergoing CL procedures experienced increased AE relative to CHD patients undergoing non-cardiac interventions outside the CL.

These Data Suggest that CHD patients undergoing Cath Lab Procedures with GA are at increased risk for AE particularly significant cardiopulmonary events.

The only feature distinguishing AE patients from the entire study population was longer duration of anesthesia. This may reflect an increased risk for AE in patients with anatomy requiring more complex manipulations or an effect of longer anesthesia.

CHD patients with diverse diagnoses, demographics, and biometrics undergoing CL procedures experienced increased AE relative to CHD patients undergoing non-cardiac interventions outside the CL.

These Data Suggest that CHD patients undergoing Cath Lab Procedures with GA are at increased risk for AE particularly significant cardiopulmonary events.

The only feature distinguishing AE patients from the entire study population was longer duration of anesthesia. This may reflect an increased risk for AE in patients with anatomy requiring more complex manipulations or an effect of longer anesthesia.

DiscussionDiscussion

Further Analysis are Planned with more data to confirm these findings

Understanding The causes for AE would allow for the development of strategies to improve patient care for CHD patients requiring GA in the Cath Lab and elsewhere.

Further Analysis are Planned with more data to confirm these findings

Understanding The causes for AE would allow for the development of strategies to improve patient care for CHD patients requiring GA in the Cath Lab and elsewhere.

ReferencesReferences

1.Baum VC et al. Pediatrics 2000, 105 (2): 332-3362. Sumpelmann R et al. Curr Opin Anesthesiol 2007, 20: 216-220.