Andersons pediatric cardiology 2298
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anticipatedcavopulmonaryanastomoses.Forinternaljugularandfemoral
access,ultrasoundguidanceshouldalwaysbeutilizedtofacilitatetheplacement
ofcentralaccess.Alternatively,severalinstitutionsprefersurgeon-placed
transthoracicintracardiaccatheters,whichcanbepositionedintheleftatrium,
rightatrium,commonatrium,pulmonaryartery,inferiorvenacava(Fontan
baffle),orinnominatevein(Glenncirculation)priortocessationofbypass.The
disadvantagesoftheselinesincludepotentialmigration,thrombosis,
dislodgement,infection,andbleedinguponremoval.Anotheralternativeisthe
useofsingle-ordouble-lumenperipherallyinsertedcentralcatheters.
DuetorepeatedIVlineplacements,establishingperipheralIVaccesscanbe
challenginginthepediatricpatientwithCHDandcanbesuccessfullyfacilitated
byusingultrasonography(Video90.1),bothinadultandpediatricpatientswith
difficultvenousaccess,whencomparedwithtraditionaltechniques.43,44This
techniquehasbeenshowntobefaster,improvepatientsatisfaction,45–47andto
facilitatecannulationofdeepervesselsnotrecognizablethroughperipheral
inspection.48,49However,useoflongercathetersisadvisabletodecreasethe
likelihoodofcomplicationsandextravasationwhenutilizingdeeperblood
vessels.47,50
Fast-TrackingandTransitionto
PostoperativeCare
Theneedforprolongedmechanicalventilationfollowingcardiacsurgeryhas
dramaticallychangedwithadvancesinsurgicalandperioperativecare.Whilethe
definitionof“earlyextubation”mayvaryfromintheOR,within6hours,or
within24hourspostoperatively,theoverallconsensusisthatthispracticehas
beenassociatedwithshortenedICUandhospitallengthsofstay,earlierinitiation
offeeding,earlierinteractionwithparents,reducedincidenceofventilatoracquiredpneumonia,andlessexposuretosedativeagents.51–53Appropriate
patientselectioniscriticalandincludesthoseforrepairofsecundumorsinus
venosusatrialseptaldefects,closureofventricularseptaldefectswithnormal
pulmonaryvascularresistance,repairofpartialatrioventricularcanaldefects,
isolatedvalvarabnormalities,subaorticmembraneresection,aswellas
bidirectionalGlennorFontanprocedures.Riskfactorsidentifiedtopredictearly
extubationfailureincludeyoungergestationalage,54prematurity,55andlower
weight.53,56,57Moreover,comorbidityorgreaterproceduralcomplexity,as
signifiedbytheRiskAdjustmentforCongenitalHeartSurgery(RACHS)score
orSocietyofThoracicSurgeons-EuropeanAssociationforCardio-Thoracic
Surgery(STAT)category,cannegativelyaffecttheprobabilityofachieving
successfulextubationintheOR.56,58Othervariablesthathavebeenidentified
includepreoperativeneedformechanicalventilatorsupport,needfor
postoperativeinotropicsupport,andpreoperativepulmonaryhypertension.54
Redocardiacsurgeryisconsideredbysometobearelativecontraindicationfor
extubationintheOR,mainlyfortheconcernofbleeding.However,if
intraoperativebloodlossisminimal,thecriteriaforextubatingthesepatients
remainsthesameasanyotherpatient.
Intraoperativeanesthesiaprotocolsfacilitatingearlyextubationincludea
relativelylow-dosenarcoticapproach,whichmightincludetheuseofa
continuousinfusionofsufentanil59andtheuseofshort-actingmusclerelaxants.
Injectionofanalgesicsintotheintrathecal,caudal,orepiduralspacewithor
withoutindwellingcathetershasbeenusedsuccessfully60toprovideeffective
postoperativeanalgesia.However,theriskofanepiduralhematomainlightof
fullsystemicheparinizationhastobeweighedagainstthebenefits.Adjunct
analgesicstobeconsideredincludeIVacetaminophen,ketorolac,and
dexmedetomidine.61,62Inadditiontoprovidinganalgesia,theadministrationof
dexmedetomidineaftercongenitalcardiacsurgerycanpreventincreased
pulmonaryarterypressures63andtachyarrhythmias.64,65
Importantly,ageneralconsensusonORextubationmustexistamong
surgeons,anesthesiologists,intensivists,andcardiologists.Inordertoimplement
asuccessfulprogram,skilledandtrainedICUnursingstaffareneededtoidentify
andreacttoearlysignsofrespiratoryandcardiaccompromise,theabilityto
performnoninvasiveventilation,andagraduatedselectionofcasesstartingwith
low-riskcandidates(basedonage,weight,cardiopulmonarybypasstimes,
RACHSIandIIcomplexities,patientslackingassociatedsyndromesand
noncardiacanomalies)andgraduallyadvancingtomorecomplexpatients.
