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Risk Factors for Longer Hospital Stay Following the Fontan Operation
Jun Sasaki1, John C Dykes, Lisa J Sosa
11Department of Cardiology, The Heart Program at Nicklaus Children's Hospital, Miami Children's Health System, Miami, FL. 2Herbert Wertheim School of Medicine, Florida International University, Miami, FL.
Insights
Higher hemoglobin, lower aortic saturation, and increased pulmonary artery pressure are risk factors for longer hospital stays in children after the Fontan operation. These findings aid in risk stratification and family counseling for this complex patient group.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Critical Care Medicine
Background:
- The Fontan operation is a complex surgical procedure for children with single ventricle physiology.
- This procedure requires significant healthcare resources, necessitating an understanding of factors influencing patient outcomes.
Purpose of the Study:
- To identify pre- and intraoperative risk factors associated with prolonged hospital stay after the Fontan operation.
- To describe the perioperative course of patients undergoing the Fontan procedure at a single institution over a 15-year period.
Main Methods:
- Retrospective cohort study of 218 consecutive patients undergoing their first Fontan operation between 2000 and 2014.
- Prolonged length of stay defined as greater than or equal to 15 days (75th percentile).
- Analysis of pre- and intraoperative variables to identify independent risk factors for prolonged stay and major complications.
Main Results:
- Independent risk factors for prolonged hospital stay included higher hemoglobin, higher mean pulmonary artery pressure, and lower aortic saturation.
- Excluding patients with hepatic vein inclusion, higher hemoglobin, lower aortic saturation, and fenestration placement were associated with prolonged stay.
- Fenestration placement and longer aortic cross-clamp time were independently associated with major complications (defined by Pediatric Cardiac Critical Care Consortium).
Conclusions:
- Preoperative factors indicating worse hypoxemia/decreased pulmonary blood flow and increased pulmonary artery pressure are linked to prolonged postoperative length of stay.
- These findings can assist in risk stratification, improve family counseling, and inform potential modifications to preoperative and postoperative management strategies for high-risk patients.
Objectives:
Children with functional single ventricle undergoing the Fontan operation consume considerable resources. The purpose of this study is to evaluate pre- and intraoperative risk factors for longer hospital stay and to describe the perioperative course at a single institution over a 15-year period.
Design:
Retrospective cohort study.
Setting:
A single pediatric cardiac ICU.
Patients:
All consecutive patients undergoing a first-time Fontan operation from 2000 to 2014.
Interventions:
None.
Measurements And Main Results:
Prolonged length of stay was defined as hospital stay greater than 75 percentile at our institution after surgery. Of 218 patients who met inclusion criteria, median length of stay was 10 days (interquartile range, 8-14 d); prolonged length of stay was defined greater than or equal to 15 days. Independent pre- and intraoperative risk factors for prolonged length of stay included higher hemoglobin (odds ratio, 1.29; p = 0.003), higher mean pulmonary artery pressure (odds ratio, 1.14; p = 0.037), and lower aortic saturation (odds ratio, 0.92; p = 0.008) in the entire group. When patients with hepatic vein inclusion (following previous Kawashima) were excluded, higher hemoglobin (odds ratio, 1.24; p = 0.027), lower aortic saturation (odds ratio, 0.92; p = 0.017), and placement of a fenestration (odds ratio, 2.438; p = 0.021) were associated with prolonged length of stay. Fifty-eight patients (26.6%) had major complications defined by Pediatric Cardiac Critical Care Consortium. Placement of a fenestration (odds ratio, 2.297; p = 0.014) and longer aortic cross-clamp time (odds ratio, 1.015; p = 0.003) were independently associated with Pediatric Cardiac Critical Care Consortium major complications.
Conclusions:
In this series, 75% of patients had a postoperative length of stay less than or equal to 2 weeks. Preoperative factors suggesting worse hypoxemia/decreased pulmonary blood flow (higher hemoglobin and lower oxygen saturation) and increased pulmonary artery pressure were associated with prolonged length of stay. These findings may help risk stratify this complex patient population, provide more accurate family counseling, and provide preliminary data for changes in preoperative timing of the Fontan and/or changes to postoperative management strategies for those at high risk for increased ICU morbidity.
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