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Management of postoperative paralysis of diaphragm in infants and children
P Kunovsky1, G A Gibson, J C Pollock
1Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK.
Insights
Phrenic nerve injury (PNI) is a complication of infant cardiac surgery, often following Blalock-Taussig shunts. Most patients experience spontaneous diaphragm recovery, making surgical intervention usually unnecessary.
Area of Science:
- Pediatric Cardiac Surgery
- Thoracic Surgery
- Pediatric Critical Care
Background:
- Phrenic nerve injury (PNI) is a recognized complication following palliative or corrective cardiac surgery in infants and children.
- The incidence and outcomes of PNI in this population require further elucidation.
Purpose of the Study:
- To determine the incidence of PNI in infants and children undergoing cardiac surgery.
- To evaluate the diagnostic utility of ultrasound and the efficacy of management strategies for PNI.
- To assess the long-term recovery of diaphragmatic function following PNI.
Main Methods:
- Prospective observational study of 86 infants and children undergoing cardiac surgery over 8 months.
- Retrospective review of 241 patients from the preceding 2 years.
- Diagnosis of PNI established by diaphragmatic ultrasound screening.
- Management included expectant care with ventilatory support and, in select cases, diaphragm plication.
Main Results:
- 11 out of 86 (12.8%) infants and children developed PNI in the prospective cohort, most frequently after Blalock-Taussig shunts.
- In the retrospective cohort, 11 out of 241 (4.6%) showed evidence of PNI.
- Spontaneous diaphragmatic recovery occurred in 90% of patients, with a mean recovery time of 40.8 days.
- Ultrasound was crucial for diagnosis, prognosis, and management decisions.
Conclusions:
- PNI is a significant complication of infant cardiac surgery, associated with morbidity and prolonged intensive care.
- Spontaneous recovery of diaphragmatic function is common, suggesting that diaphragm plication can often be avoided.
- Diaphragmatic ultrasound is a valuable tool for diagnosing PNI and guiding patient management.
Abstract:
During an 8-month period, 86 consecutive infants and children under 2 years of age underwent palliative or corrective cardiac surgery, of whom 11 subsequently developed phrenic nerve injury (PNI). This was seen most frequently following classic or modified Blalock-Taussig shunts. The diagnosis was established by ultrasound screening of the diaphragm, and patients were initially managed expectantly with ventilatory support. In nine patients no further management was necessary with demonstrated return of diaphragmatic function. The remaining two patients underwent plication of the diaphragm. The mean time to diaphragmatic recovery was 40.8 days and was more prolonged in patients with paradoxical, as opposed to absent, diaphragmatic movement. There were no deaths in the series. A further retrospective review of 241 patients of similar age undergoing similar surgery over the preceding 2 years revealed evidence of PNI in 11 (4.6%). Recovery of diaphragmatic function was documented in all except one patient who died. Based on these results we believe that although PNI is associated with considerable morbidity, and frequently a long stay in Intensive Care, there is evidence of spontaneous recovery of diaphragmatic function in 90% of the patients. Consequently, plication of the diaphragm can usually be avoided. Ultrasound scanning is extremely useful in establishing the diagnosis and offers assistance in predicting prognosis and deciding management.