Cardiology in the Young

Original Article

Postoperative course in the cardiac intensive care unit following the first stage of Norwood reconstruction

Gil Wernovskya1a2 c1, Marijn Kuijpersa6, Maaike C. Van Rossema6, Bradley S. Marinoa1a2, Chitra Ravishankara1a2, Troy Domingueza2, Rodolfo I. Godineza2, Kathryn M. Doddsa1a7, Richard F. Ittenbacha5, Susan C. Nicolsona3, Geoffrey L. Birda1a2, J. William Gaynora4, Thomas L. Spraya4 and Sarah Tabbutta1a2

a1 From the Department of Pediatrics, Division of Pediatric Cardiology, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

a2 Department of Anesthesia and Critical Care Medicine, Divisions of Critical Care Medicine, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

a3 Department of Anesthesia and Critical Care Medicine, Divisions of Cardiothoracic Anesthesia), The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

a4 The Department of Surgery, Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

a5 Department of Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

a6 University of Utrecht Faculty of Medicine, Utrecht, Netherlands

a7 The University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA

Abstract

The medical records of all patients born between 1 September, 2000, and 31 August, 2002, and undergoing the first stage of Norwood reconstruction, were retrospectively reviewed for details of the perioperative course. We found 99 consecutive patients who met the criterions for inclusion. Hospital mortality for the entire cohort was 15.2%, but was 7.3%, with 4 of 55 dying, in the setting of a “standard” risk profile, as opposed to 25.0% for those with a “high” risk profile, 11 of 44 patients dying in this group. Extracorporeal membrane oxygenation was utilized in 7 patients, with 6 deaths. Median postoperative length of stay in the hospital was 14 days, with a range from 2 to 85 days, and stay in the cardiac intensive care unit was 11 days, with a range from 2 to 85 days. Delayed sternal closure was performed in 18.2%, with a median of 1 day until closure, with a range from zero to 5 days. Excluding isolated delayed sternal closure, and cannulation and decannulation for extracorporeal support, 24 patients underwent 33 cardiothoracic reoperations, including exploration for bleeding in 12, diaphragmatic plication in 4; shunt revision in 4, and other procedures in 13. The median duration of total mechanical ventilation was 4.0 days, with a range from 0.7 to 80.5 days. Excluding those who died, the median total duration of mechanical ventilation was 3.8 days, with a range from 0.9 to 46.3 days. Reintubation for cardiorespiratory failure or upper airway obstruction was performed in 31 patients. Postoperative electroencephalographic and/or clinical seizures occurred in 13 patients, with 7 discharged on anti-convulsant medications. Postoperative renal failure, defined as a level of creatinine greater than 1.5 mg/dl, was present in 13 patients. Eleven had significant thrombocytopenia, with fewer than 20,000 platelets per μl, and injury to the vocal cords was identified in eight patients. Risk factors for longer length of stay included lower Apgar scores, preoperative intubation, early reoperations, reintubation and sepsis, but not weight at birth, genetic syndromes, the specific surgeon, or the duration of surgery.

Although mortality rates after the first stage of reconstruction continue to fall, the course in the intensive care unit is remarkable for significant morbidity, especially involving the cardiac, pulmonary and central nervous systems. These patients utilize significant resources during the first hospitalization. Further studies are necessary to stratify the risks faced by patients with hypoplasia of the left heart in whom the first stage of Norwood reconstruction is planned, to determine methods to reduce perioperative morbidity, and to determine the long-term implications of short-term complications, such as diaphragmatic paresis, injury to the vocal cords, prolonged mechanical ventilation, and postoperative seizures.

(Accepted May 09 2007)

Correspondence:

c1 Correspondence to: Gil Wernovsky MD, Director, Program Development, The Cardiac Center at The Children’s Hospital of Philadelphia, Professor of Pediatrics, University of Pennsylvania School of Medicine, Pediatric Cardiology, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA. Tel: 215 590 6067; Fax: 215 590 4620; E-mail: wernovsky@email.chop.edu

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