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Impact of diaphragmatic paralysis after cardiothoracic surgery in children
M de Leeuw1, J M Williams, R M Freedom
1Division of Cardiology, University of Toronto, The Hospital for Sick Children, Ontario, Canada.
Insights
Diaphragmatic paralysis after pediatric cardiothoracic surgery affects 1.6% of children, significantly increasing hospital stays. Early recovery is rare, especially in smaller patients requiring mechanical ventilation.
Area of Science:
- Pediatric Cardiothoracic Surgery
- Pediatric Pulmonology
- Pediatric Neurology
Background:
- Phrenic nerve injury leading to diaphragmatic paralysis is a known complication of cardiothoracic surgery.
- The incidence and clinical impact of this complication in pediatric populations require further elucidation.
Purpose of the Study:
- To determine the prevalence of diaphragmatic paralysis following pediatric cardiothoracic surgery.
- To assess the clinical impact and associated risk factors of diaphragmatic paralysis in children.
Main Methods:
- Retrospective review of 170 cases of diaphragmatic paralysis in 168 children who underwent cardiothoracic surgery between 1985 and 1997.
- Analysis of patient demographics, surgical details, postoperative course, diagnostic findings, management, and follow-up status.
Main Results:
- The prevalence of diaphragmatic paralysis was 1.6%.
- Factors associated with increased postoperative hospital stay included lower patient weight, prior surgeries, bilateral paralysis, delayed diagnosis, mechanical ventilation, and diaphragmatic plication.
- Confirmed recovery of diaphragmatic function before hospital discharge was observed in only 15 cases.
Conclusions:
- Diaphragmatic paralysis remains a significant complication of pediatric cardiothoracic surgery, impacting morbidity.
- Smaller patients with bilateral diaphragmatic paralysis requiring mechanical ventilation represent a high-risk subgroup.
- Increased diagnostic suspicion and proactive management are recommended, as spontaneous recovery is infrequent.
Objectives:
We sought to determine the prevalence and clinical impact of diaphragmatic paralysis caused by phrenic nerve injury after cardiothoracic surgery in children.
Methods:
A search of cardiology, radiology, and hospital databases identified 170 episodes of diaphragmatic paralysis after cardiothoracic surgery in 168 children operated on from 1985 to 1997. Medical records were reviewed to determine demographics, details of the operation and postoperative course, diagnostic features and management of diaphragmatic paralysis, and follow-up status.
Results:
The prevalence of diaphragmatic paralysis was 1.6% (95% confidence interval 1.4%-1.8%). Median age at operation was 6 months (range <1 day-14.4 years). Median time from the operation to the initial investigation was 5 days (range <1 day-61 days), with 57% of patients receiving mechanical ventilation at diagnosis. Diaphragmatic plication was performed in 40% of the patients at a median interval from the initial investigation of 15 days (range 3 days-11.1 months). Significant independent factors associated with increased postoperative hospital stay were lower patient weight at operation, previous cardiothoracic operations, bilateral diaphragmatic paralysis, increased interval from operation to investigation, mechanical ventilation at the time of investigation, and diaphragmatic plication. Confirmed recovery of diaphragmatic function was noted before hospital discharge in only 15 episodes.
Conclusions:
Diaphragmatic paralysis complicating cardiothoracic surgery continues to occur in the current era, with a significant impact on morbidity. Smaller patients with bilateral hemidiaphragmatic paralysis, requiring mechanical ventilation, may represent a higher risk subgroup to target for increased diagnostic suspicion and more aggressive management; early spontaneous recovery is rare.