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Perioperative events in children with pulmonary hypertension undergoing non-cardiac procedures
Meghan L Bernier1, Ariel I Jacob1, Joseph M Collaco2
11 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Insights
Children with pulmonary hypertension (PH) face increased perioperative risks during procedures. Severe PH and thoracic surgeries elevate the likelihood of cardiac arrest and death, highlighting the need for careful management.
Area of Science:
- Pediatric Cardiology
- Anesthesiology
- Critical Care Medicine
Background:
- Limited prior research suggests elevated adverse perioperative outcomes in pediatric patients with pulmonary hypertension (PH).
- Children with PH undergoing non-cardiac procedures and cardiac catheterizations may experience higher complication rates.
- Understanding these risks is crucial for optimizing perioperative care in this vulnerable population.
Purpose of the Study:
- To examine the relationship between PH severity, etiology, procedure type, and perioperative outcomes in children.
- To identify specific risk factors associated with major and minor adverse events during procedures in pediatric PH patients.
- To evaluate the impact of preoperative vasodilator therapy on perioperative complications.
Main Methods:
- Retrospective cohort study of 77 children with active or pharmacologically controlled PH undergoing 148 procedures (2006-2014).
- Analysis of preoperative characteristics and perioperative courses, including major events (e.g., cardiac arrest, death) and minor events.
- Statistical analysis to determine associations between PH severity/etiology, procedure type, and event occurrence.
Main Results:
- Major adverse events, including cardiac arrest and death, were more frequent in patients with severe baseline PH (P=0.006) and associated with procedure type (P=0.05).
- Common PH etiologies included bronchopulmonary dysplasia (46.7%) and congenital heart disease (29.9%).
- Preoperative inhaled nitric oxide and prostacyclin analog therapies were linked to fewer minor events (OR=0.32, P=0.046 and OR=0.24, P=0.008, respectively), but not major events.
Conclusions:
- Children with PH exhibit an increased risk of perioperative complications, with severe PH and thoracic procedures correlating with higher rates of cardiac arrest and mortality.
- Preoperative pulmonary vasodilator therapy may mitigate the incidence of minor perioperative events.
- Further prospective studies are warranted to confirm these findings and refine perioperative management strategies for pediatric PH patients.
Abstract:
Prior limited research indicates that children with pulmonary hypertension (PH) have higher rates of adverse perioperative outcomes when undergoing non-cardiac procedures and cardiac catheterizations. We examined a single-center retrospective cohort of children with active or pharmacologically controlled PH who underwent cardiac catheterization or non-cardiac surgery during 2006-2014. Preoperative characteristics and perioperative courses were examined to determine relationships between the severity or etiology of PH, type of procedure, and occurrence of major and minor events. We identified 77 patients who underwent 148 procedures at a median age of six months. The most common PH etiologies were bronchopulmonary dysplasia (46.7%), congenital heart disease (29.9%), and congenital diaphragmatic hernia (14.3%). Cardiac catheterizations (39.2%), and abdominal (29.1%) and central venous access (8.9%) were the most common procedures. Major events included failed planned extubation (5.6%), postoperative cardiac arrest (4.7%), induction or intraoperative cardiac arrest (2%), and postoperative death (1.4%). Major events were more frequent in patients with severe baseline PH ( P = 0.006) and the incidence was associated with procedure type ( P = 0.05). Preoperative inhaled nitric oxide and prostacyclin analog therapies were associated with decreased incidence of minor events (odds ratio [OR] = 0.32, P = 0.046 and OR = 0.24, P = 0.008, respectively), but no change in the incidence of major events. PH etiology was not associated with events ( P = 0.24). Children with PH have increased risk of perioperative complications; cardiac arrest and death occur more frequently in patients with severe PH and those undergoing thoracic procedures. Risk may be modified by using preoperative pulmonary vasodilator therapy and lends itself to further prospective studies.
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