Andersons pediatric cardiology 2299
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AnesthesiaandSedationforDiagnostic
andInterventionalCatheterization
Cardiaccatheterizationplaysanincreasingroleinthemanagementofpediatric
andadultpatientswithCHD.Moreover,hybridcapabilitiesinthecatheterization
suiteareblendingthedifferencesbetweenORandcathlabandpermitinvasive
proceduresinvolvingbothsurgeonsandinterventionalcardiologists.Delivering
anesthesiainthisenvironmentcanbechallengingduetolimitationsinphysical
spaceandaccesstothepatient,exposuretoionizingradiation,andincreasing
medicalcomplexityofthepatientpopulationandproceduralintricacies.
Historically,sedationwasfrequentlyperformedbythecardiaccatheterization
laboratory'sstaffandsupervisedbytheproceduralist.However,giventhe
increasedproceduralandmedicalcomplexities,dedicatedprovidersnotinvolved
inthecatheterizationprocedure,suchaspediatricanesthesiologists,should
managethesepatientsmonitoringandsedationneeds.Pediatriccardiac
anesthesiologistsarebestqualifiedtohandlethecontinuumfromlightsedation
togeneralanesthesiaforthesepatients,whichincomplexityareoften
indistinguishablefromsurgicalpatients.Accordingly,considerationsfortypeof
anesthetic,choiceofmonitoring,airwaymanagement,andvascularaccessfor
patientsundergoingdiagnosticcatheterizations,interventions,and
electrophysiologicassessmentsandablationsinthecathlabareoften
indistinguishablefromrequirementsforpatientswithCHDcaredforinthe
operatingroom.However,sedationismorefrequentlyemployedinthecathlab
setting,especiallyforelectrophysiologicprocedures,includingablationof
aberrantelectricalpathwaysandevenwheninstitutingtrachealintubation,
patientsarealmostalwaysextubatedfollowingcathlabprocedure.
Hemodynamicalterationsandcardiacarrhythmiasarenotuncommoninthecath
labsettingandsituationalawarenessandteamworkareessentialtomaintain
patientsafety,asareanticipationandpreparationfortherareoccurrenceoflifethreateningcomplications.
AnesthesiainPatientsWithCongenital
HeartDiseaseforNoncardiacSurgery
WhiletheoverallincidenceofCHDhasremainedstableoverthepast50years,
thepopulationofolderchildrenandadultswithCHDisgrowingbetween1%
and5%peryear.Advancesinsurgicalproceduresandtechniques,inconcert
withimprovementsindiagnosis,anestheticpractices,intensivecare,andmedical
treatmentshavetransformedmanypreviouslyfatallesionsintomanageable
chronicconditions.66–69Accordingly,agrowingcohortofolderchildrenand
youngadultswithCHDpresentfornoncardiacsurgeryorinvasive
procedures.70–72Ithasbeenestimatedthatnearlyone-halfofchildrenwithCHD
willrequireadditionalnoncardiacsurgeriesandprocedures,withassociated
anestheticcareovertheirlifetime.71Multiplestudieshaveshownthatthisgroup
carriesanincreasedriskofperioperativemortalityandmorbidity,comparedwith
childrenwithoutCHD.73–82
Specifically,ananalysisofthePediatricPerioperativeCardiacArrestRegistry
identifiedchildrenwithCHDtorepresent34%ofthe373casesofanesthesiarelatedcardiacarrestsand75%ofresultantdeathscouldbeattributedtothree
distinctdefects,whichwereaorticstenosis,cardiomyopathy,andsingleventricle
lesions.74Faraoniandcolleagues73lookedatdatafromthe2012pediatric
databaseoftheAmericanCollegeofSurgeonsNationalSurgicalQuality
ImprovementProgram.Afterpropensitymatching,theyidentified2805children
withminor,1272withmajor,and417withsevereCHD(Table90.2).Childrenin
eachsubgroupwerematchedandcomparedwithcontrolswithoutCHDwho
underwentnoncardiacsurgeryofcomparablecomplexity.Theincidenceof
overallmortalitywassignificantlyhigherinchildrenwithmoderate(3.9%)and
severe(8.2%)CHDcomparedwiththeirrespectivecontrols(1.7%[P<.001]
and1.2%[P=.001]).Preoperativemarkersofcriticalillness(e.g.,inotropic
support,mechanicalventilation,preoperativeCPR,andacuteorchronicinjury),
severityofCHD,andspecificallysingleventriclephysiology,wereidentifiedas
predictorsofin-hospitalmortality.Otherstudieshavesimilarlyidentified
childrenwithsingleventriclephysiologytobeathighriskforperioperative
complications.74,83,84Atthesametimethispatientpopulationfrequently
requiresnoncardiacsurgery;bysomeestimates17%priortotheirbidirectional
Glennshunt,85eventhoughitisgenerallyrecommendedthatelectivenoncardiac
proceduresbepostponeduntilafterthesuperiorcavopulmonaryshunt.84–86In
addition,childrenwithuncorrectedCHD,documentedpulmonary
hypertension,75,87,88ventriculardysfunctionrequiringmedications,listedfor
hearttransplant(“severeCHD,”seeTable90.2),andthosewithsupravalvar
aorticstenosiswithorwithoutWilliamssyndrome89,90alsosufferasignificantly
higherincidenceofin-hospitalmortalitycomparedwithchildrenwithresidual
hemodynamiclesionsfollowingrepairofCHD(classifiedas“majorCHD”).
Table90.2
ACSNSQIPClassificationofCHDBasedonResidualLesionBurdenandFunctionalStatus
Classification DefinitionandCriteria
MinorCHD
Cardiacconditionwithorwithoutmedicationandmaintenance(e.g.,atrialseptaldefect,
small-to-moderateventricularseptaldefectwithnosymptoms)
Repairofcongenitalheartdefectwithnormalcardiovascularfunctionandnomedication
MajorCHD
Repairofcongenitalheartdefectwithresidualhemodynamicabnormalitywithorwithout
medications(e.g.,tetralogyofFallotwithwideopenpulmonaryinsufficiency,hypoplasticleft
heartsyndromeincludingstage1repair)
SevereCHD
Uncorrectedcyanoticheartdisease
Patientswithanydocumentedpulmonaryhypertension
Patientswithventriculardysfunctionrequiringmedications
Listedforhearttransplant
ACSNSQIP,AmericanCollegeofSurgeonsNationalSurgicalQualityImprovementProgram;
CHD,congenitalheartdisease.
Giventheincreasedriskofthesepatientsundergoingnoncardiacsurgery,itis
importanttoimplementstringentrisk/benefitanalysesandadequatelyallocate
resourcesrelatedtomonitoring,postoperativedisposition,andmanpower,such
ascardiology,cardiacanesthesia,andcardiacICUsupport.91Institutional
variabilityexistsinwhetherpatientswithcomplexCHDformajorgeneral
surgeryareanesthetizedbypediatriccardiacorgeneralpediatric
anesthesiologists.92,93However,providersneedtobeintimatelyfamiliarwiththe
underlyingcardiacpathophysiologyandpreparedtointerveneinorderto
improveoutcomesinthischallengingpatientpopulation.
