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Perioperative Risk Assessment in Children With Congenital Heart Disease Undergoing Noncardiac Procedures
Rahul G Baijal1, Hediye Fakhar1, Jamie Sinton2
1Department of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
Insights
A robust model identifies 5 predictors for severe perioperative complications in children with congenital heart disease undergoing noncardiac procedures. These findings aid in risk stratification and guide anesthetic care decisions.
Area of Science:
- Pediatric Anesthesiology
- Congenital Heart Disease
- Surgical Risk Stratification
Background:
- Children with congenital heart disease (CHD) often require noncardiac surgery or diagnostic procedures.
- Risk stratification for perioperative cardiopulmonary complications in this population is crucial for patient safety.
Purpose of the Study:
- To develop and validate a risk-stratification model for perioperative cardiopulmonary complications in children with CHD undergoing noncardiac procedures.
- To utilize established institutional guidelines for risk assessment.
Main Methods:
- A retrospective cohort study involving 1,005 children (birth to 19 years) with CHD undergoing noncardiac procedures between January 2017 and December 2018.
- Multivariate analysis was used to identify predictors of severe perioperative complications (cardiac arrest or death within 30 days).
Main Results:
- The incidence of severe perioperative complications was 1.6%.
- Significant predictors for severe complications included age, emergent surgery, preoperative renal abnormality, preoperative mechanical ventilation, and preoperative pericardial effusion.
- The model demonstrated high accuracy for predicting severe complications (AUC = 0.936) but lower accuracy for moderate complications (AUC = 0.679).
Conclusions:
- A robust model with 5 predictors for severe perioperative complications was developed, aiding risk stratification for children with CHD.
- Standard markers of critical illness did not predict moderate complications, suggesting that general pediatric anesthesiologists can manage many of these cases with established guidelines.
Objectives:
To risk-stratify children with congenital heart disease undergoing noncardiac surgery or diagnostic procedures for perioperative cardiopulmonary complications using the authors' established institutional guidelines.
Design:
A retrospective cohort study.
Setting:
The study was conducted in an academic, tertiary-care children's hospital.
Participants:
A total of 1,005 children, from birth to 19 years of age with a diagnosis of congenital heart disease, who underwent a noncardiac surgery or diagnostic procedure from January 2017 to December 2018, were included in the study.
Interventions:
None.
Measurements And Main Results:
The incidence of a severe perioperative complication, defined as a perioperative cardiac arrest or death within 30 days of the procedure, was 1.6%. Age, an emergent surgery/procedure, a preoperative renal abnormality, preoperative mechanical ventilation, and a preoperative pericardial effusion were significant for severe perioperative complications, in the multivariate analysis. The area under the receiver operating characteristic curve for severe complications was 0.936. However, the area under the curve for moderate perioperative complications was 0.679, in which moderate complications were defined as (1) an escalation in anticipated postoperative disposition (from planned disposition), (2) an escalation in postoperative disposition (from preoperative location), (3) an escalation of preoperative airway support, (4) an administration of any intraoperative vasoactive medication/infusion, (5) a noncardiac surgery reoperation within 30 days of the procedure (if related to the primary procedure or change in physiology), or (6) unplanned readmission with 24 hours of the procedure.
Conclusions:
A robust model for severe perioperative complications was developed within the authors' institutional clinical guidelines, identifying 5 predictors for perioperative cardiac arrest or death. The usual markers of critical illness were not found to be predictive of a moderate perioperative complication, regardless of the level of anesthesiologist training, suggesting that many of these children with congenital heart disease undergoing noncardiac procedures can be treated by a general pediatric anesthesiologist rather than a pediatric cardiac anesthesiologist within an institution that has or can establish clinical guidelines for these children.
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