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Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional
Alok Kumar1, H R Ramamurthy2, Nikhil Tiwari3
1Department of Anaesthesia & Critical Care, Army Hospital (Research & Referral), Delhi Cantt, New Delhi 110010 India.
Insights
Fast-tracking with thoracic epidural analgesia (TEA) enables early extubation in 59% of pediatric cardiac surgery patients. This approach is safe and effective, leading to shorter hospital stays for appropriate candidates.
Area of Science:
- Cardiology
- Anesthesiology
- Pediatric Surgery
Background:
- Paediatric cardiac surgery often involves prolonged mechanical ventilation.
- Fast-tracking aims to expedite recovery and reduce hospital stay.
- Thoracic epidural analgesia (TEA) is a key component in multimodal pain management.
Purpose of the Study:
- To evaluate the success of fast-tracking in infants and children undergoing congenital heart surgery.
- To assess the feasibility and outcomes of early extubation using continuous thoracic epidural analgesia (TEA).
Main Methods:
- Retrospective study of 390 children (≤12 years) undergoing congenital heart surgery.
- Analysis of data from January 2018 to December 2019 at a tertiary care hospital.
- Inclusion of patients receiving general anesthesia with continuous TEA.
Main Results:
- Median extubation time was 2 hours 25 minutes; 55% extubated within 6 hours.
- Early extubation group had significantly shorter hospital stays (4.1 vs 6.9 days, p=0.004).
- Reintubation rate was 6.9%; 13 patients died postoperatively. Low intraoperative temperature and bypass time >90 min predicted fast-tracking failure.
Conclusions:
- A multimodal approach including TEA, propofol, and dexmedetomidine facilitates early extubation in 59% of pediatric cardiac surgeries.
- Fast-tracking is feasible and associated with safe, superior outcomes in selected pediatric cardiac surgery patients.
- Factors like younger age, Down syndrome, and specific surgical scores did not impede early extubation.
Objective:
To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under general anaesthesia with continuous thoracic epidural analgesia (TEA).
Methodology:
It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12 years or younger, were operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71 patients, data from the remaining 390 patients were analysed.
Measurements And Main Results:
The median time for extubation after intensive care unit admission was 2 h and 25 min (0-20 h). Extubation within 6 h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004) than patients in the ventilated group. Reintubation was required in 27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively and cardiopulmonary bypass time > 90 min significantly predicted failure in fast-tracking with an odds ratio (OR) = 1.27; CI: 1.18-1.38 and OR = 2.3; CI: 1.8-2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic score did not adversely affect early extubation, contrary to contemporary concerns.
Conclusions:
A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery.
Supplementary Information:
The online version contains supplementary material available at 10.1007/s12055-022-01373-8.
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