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

Published online by Cambridge University Press:  07 November 2007

Gil Wernovsky*
Affiliation:
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 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
Marijn Kuijpers
Affiliation:
University of Utrecht Faculty of Medicine, Utrecht, Netherlands
Maaike C. Van Rossem
Affiliation:
University of Utrecht Faculty of Medicine, Utrecht, Netherlands
Bradley S. Marino
Affiliation:
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 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
Chitra Ravishankar
Affiliation:
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 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
Troy Dominguez
Affiliation:
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
Rodolfo I. Godinez
Affiliation:
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
Kathryn M. Dodds
Affiliation:
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 The University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
Richard F. Ittenbach
Affiliation:
Department of Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Susan C. Nicolson
Affiliation:
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
Geoffrey L. Bird
Affiliation:
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 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
J. William Gaynor
Affiliation:
The Department of Surgery, Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Thomas L. Spray
Affiliation:
The Department of Surgery, Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Sarah Tabbutt
Affiliation:
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 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
*
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

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.

Type
Original Article
Copyright
Copyright © Cambridge University Press 2007

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References

1. Gaynor, JW, Mahle, WT, Cohen, MI, et al. . Risk factors for mortality after the Norwood procedure. Eur J Cardiothorac Surg 2002; 22: 8289.Google Scholar
2. Bove, EL, Lloyd, TR. Staged reconstruction for hypoplastic left heart syndrome. Contemporary results. Ann Surg 1996; 224: 387394.Google Scholar
3. Stasik, CN, Gelehrter, S, Goldberg, CS, Bove, EL, Devaney, EJ, Ohye, RG. Current outcomes and risk factors for the Norwood procedure. J Thorac Cardiovasc Surg 2006; 131: 412417.Google Scholar
4. Tabbutt, S, Dominguez, TE, Ravishankar, C, et al. . Outcomes after the stage I reconstruction comparing the right ventricular to pulmonary artery conduit with the modified Blalock Taussig shunt. Ann Thorac Surg 2005; 80: 15821590.Google Scholar
5. Cua, CL, Thiagarajan, RR, Gauvreau, K, et al. . Early postoperative outcomes in a series of infants with hypoplastic left heart syndrome undergoing stage I palliation operation with either modified Blalock-Taussig shunt or right ventricle to pulmonary artery conduit. Pediatr Crit Care Med 2006; 7: 238244.Google Scholar
6. Ghanayem, NS, Hoffman, GM, Mussatto, KA, et al. . Home surveillance program prevents interstage mortality after the Norwood procedure. J Thorac Cardiovasc Surg 2003; 126: 13671377.Google Scholar
7. Tweddell, JS, Hoffman, GM, Mussatto, KA, et al. . Improved survival of patients undergoing palliation of hypoplastic left heart syndrome: lessons learned from 115 consecutive patients. Circulation 2002; 106: I82I89.Google Scholar
8. Jeffries, HE, Wells, WJ, Starnes, VA, Wetzel, RC, Moromisato, DY. Gastrointestinal morbidity after Norwood palliation for hypoplastic left heart syndrome. Ann Thorac Surg 2006; 81: 982987.Google Scholar
9. Bacha, EA, Daves, S, Hardin, J, et al. . Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy. J Thorac Cardiovasc Surg 2006; 131: 163171.Google Scholar
10. Caldarone, CA, Benson, LN, Holtby, H, Van Arsdell, GS. Main pulmonary artery to innominate artery shunt during hybrid palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2005; 130: e1e2.Google Scholar
11. Galantowicz, M, Cheatham, JP. Lessons learned from the development of a new hybrid strategy for the management of hypoplastic left heart syndrome. Pediatr Cardiol 2005; 26: 190199.Google Scholar
12. Pizarro, C, Mroczek, T, Malec, E, Norwood, WI. Right ventricle to pulmonary artery conduit reduces interim mortality after stage 1 Norwood for hypoplastic left heart syndrome. Ann Thorac Surg 2004; 78: 19591963.CrossRefGoogle Scholar
13. Sano, S, Ishino, K, Kawada, M, Honjo, O. Right ventricle-pulmonary artery shunt in firststage palliation of hypoplastic left heart syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7: 2231.Google Scholar
14. Sano, S, Ishino, K, Kado, H, et al. . Outcome of right ventricle-to-pulmonary artery shunt in firststage palliation of hypoplastic left heart syndrome: a multi-institutional study. Ann Thorac Surg 2004; 78: 19511957.Google Scholar
15. Takeda, Y, Asou, T, Yamamoto, N, Ohara, K, Yoshimura, H, Okamoto, H. Arch reconstruction without circulatory arrest in neonates. Asian Cardiovasc Thorac Ann 2005; 13: 337340.CrossRefGoogle ScholarPubMed
16. Burke, RP, Zahn, EM, Rossi, AF. Achieving resonance in a programme for congenital cardiac surgery. Cardiol Young 2004; 14: 7582.Google Scholar
17. De Oliveira, NC, Van Arsdell, GS. Practical use of alpha blockade strategy in the management of hypoplastic left heart syndrome following stage one palliation with a Blalock-Taussig shunt. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7: 1115.CrossRefGoogle ScholarPubMed
18. Shen, I, Ungerleider, RM. Routine use of mechanical ventricular assist following the Norwood procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7: 1621.Google Scholar
19. Gaynor, JW, Kuypers, M, van Rossem, M, et al. . Haemodynamic changes during modified ultrafiltration immediately following the first stage of the Norwood reconstruction. Cardiol Young 2005; 15: 47.Google Scholar
20. Spray, TL. Stage I reconstruction. In: Rychik, J, Wernovsky, G (eds). Hypoplastic Left Heart Syndrome. Kluwer Academic Publishers, Boston, 2003, pp 89104.CrossRefGoogle Scholar
21. Steven, JM, Nicolson, SC. Anesthetic Management for HLHS. In: Rychik, J, Wernovsky, G (eds). Hypoplastic Left Heart Syndrome. Kluwer Academic Publishers, Boston, 2003, pp 167192.Google Scholar
22. Tabbutt, S, Wernovsky, G. Pre-operative management. In: Rychik, J, Wernovsky, G (eds). Hypoplastic Left Heart Syndrome. Kluwer Academic Publishers, Boston, 2003, pp 6989.CrossRefGoogle Scholar
23. Wernovsky, G, McElhinney, DB, Tabbutt, S. Stage I postoperative management. In: Rychik, J, Wernovsky, G (eds). Hypoplastic Left Heart Syndrome. Kluwer Academic Publishers, Boston, 2003, pp 105128.Google Scholar
24. Zuppa, AF, Nicolson, SC, Adamson, PC, et al. . Population pharmacokinetics of milrinone in neonates with hypoplastic left heart syndrome undergoing stage I reconstruction. Anesth Analg 2006; 102: 10621069.Google Scholar
25. Hoffman, TM, Wernovsky, G, Atz, AM, et al. . Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation 2003; 107: 9961002.CrossRefGoogle ScholarPubMed
26. Kulik, TJ, Moler, FW, Palmisano, JM, et al. . Outcome-associated factors in pediatric patients treated with extracorporeal membrane oxygenator after cardiac surgery. Circulation 1996; 94 (Suppl): I6368.Google ScholarPubMed
27. Wernovsky, G, Wypij, D, Jonas, RA, et al. . Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants – a comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 1995; 92: 22262235.Google Scholar
28. Tukey, JW, Ciminera, JL, Heyse, JF. Testing the statistical certainty of a response to increasing doses of a drug. Biometrics 1985; 41: 295301.Google Scholar
29. Zhang, J, Quan, H, Ng, J, Stepanavage, ME. Some statistical methods for multiple endpoints in clinical trials. Control Clin Trials 1997; 18: 204221.CrossRefGoogle ScholarPubMed
30. Norwood, WI, Lang, P, Hansen, DD. Physiologic repair of aortic atresia hypoplastic left heart syndrome. N Engl J Med 1983; 308: 2326.Google Scholar
31. Freedom, RM, Hamilton, R, Yoo, SJ, et al. . The Fontan procedure: analysis of cohorts and late complications. Cardiol Young 2000; 10: 307331.Google Scholar
32. Gaynor, JW, Bridges, ND, Cohen, MI, et al. . Predictors of outcome after the Fontan operation: is hypoplastic left heart syndrome still a risk factor? J Thorac Cardiovasc Surg 2002; 123: 237245.Google Scholar
33. Mitchell, ME, Ittenbach, RF, Gaynor, JW, Wernovsky, G, Nicolson, S, Spray, TL. Intermediate outcomes after the Fontan procedure in the current era. J Thorac Cardiovasc Surg 2006; 131: 172180.CrossRefGoogle ScholarPubMed
34. Pizarro, C, Mroczek, T, Gidding, SS, Murphy, JD, Norwood, WI. Fontan completion in infants. Ann Thorac Surg 2006; 81: 22432248.CrossRefGoogle ScholarPubMed
35. Thies, WR, Breymann, T, Boethig, D, Blanz, U, Meyer, H, Koerfer, R. Results of staged reconstruction for hypoplasia of the left heart: an experience of 12 years from one institution. Cardiol Young 2003; 13: 509518.Google Scholar
36. Friesen, RH, Perryman, KM, Weigers, KR, Mitchell, MB, Friesen, RM. A trial of fresh autologous whole blood to treat dilutional coagulopathy following cardiopulmonary bypass in infants. Paediatr Anaesth 2006; 16: 429435.Google Scholar
37. Jaggers, J, Lawson, JH. Coagulopathy and inflammation in neonatal heart surgery: Mechanisms and strategies. Ann Thorac Surg 2006; 81: S2360S2366.Google Scholar
38. Manno, CS, Hedberg, KW, Kim, HC, et al. . Comparison of the hemostatic effects of fresh whole blood, stored whole blood, and components after open heart surgery in children. Blood 1991; 77: 930936.Google Scholar
39. De Oliveira, NC, Ashburn, DA, Khalid, F, et al. . Prevention of early sudden circulatory collapse after the Norwood operation. Circulation 2004; 110: II133II138.CrossRefGoogle ScholarPubMed
40. Drinkwater, DC, Aharon, AS, Quisling, SV, et al. . Modified Norwood operation for hypoplastic left heart syndrome. Ann Thorac Surg 2001; 72: 20812086.Google Scholar
41. Graham, EM, Forbus, GA, Bradley, SM, Shirali, GS, Atz, AM. Incidence and outcome of cardiopulmonary resuscitation in patients with shunted single ventricle: Advantage of right ventricle to pulmonary artery shunt. J Thorac Cardiovasc Surg 2006; 131: e7e8.CrossRefGoogle ScholarPubMed
42. Hintz, SR, Benitz, WE, Colby, CE, Sheehan, AM, Rycus, P, Van Meurs, KP. Utilization and outcomes of neonatal cardiac extracorporeal life support: 1996–2000. Pediatr Crit Care Med 2005; 6: 3338.Google Scholar
43. Malec, E, Januszewska, K, Kolcz, J, Mroczek, T. Right ventricle-to-pulmonary artery shunt versus modified Blalock-Taussig shunt in the Norwood procedure for hypoplastic left heart syndrome – influence on early and late haemodynamic status. Eur J Cardiothorac Surg 2003; 23: 728733.Google Scholar
44. Ravishankar, C, Dominguez, TE, Kreutzer, J, et al. . Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome. Pediatr Crit Care Med 2006; 7: 319323.Google Scholar
45. Wright, GE, Crowley, DC, Charpie, JR, Ohye, RG, Bove, EL, Kulik, TJ. High systemic vascular resistance and sudden cardiovascular collapse in recovering Norwood patients. Ann Thorac Surg 2004; 77: 4852.CrossRefGoogle ScholarPubMed
46. Gillespie, M, Kuijpers, M, van Rossem, M, et al. . Determinants of intensive care unit length of stay for infants undergoing cardiac surgery. Congenit Heart Dis 2006; 1: 148151.Google Scholar
47. Skinner, ML, Halstead, LA, Rubinstein, CS, Atz, AM, Andrews, D, Bradley, SM. Laryngopharyngeal dysfunction after the Norwood procedure. J Thorac Cardiovasc Surg 2005; 130: 12931301.Google Scholar
48. Bracco, D, Favre, JB, Bissonnette, B, et al. . Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 2001; 27: 137145.CrossRefGoogle Scholar
49. Mahle, WT, Visconti, KJ, Freier, MC, et al. . Relationship of surgical approach to neurodevelopmental outcomes in hypoplastic left heart syndrome. Pediatrics 2006; 117: e90e97.Google Scholar
50. Newburger, JW, Wypij, D, Bellinger, DC, et al. . Length of stay after infant heart surgery is related to cognitive outcome at age 8 years. J Pediatr 2003; 143: 6773.Google Scholar
51. Krasemann, T, Fenge, H, Kehl, HG, et al. . A decade of staged Norwood palliation in hypoplastic left heart syndromein a midsized cardiosurgical center. Pediatr Cardiol 2005; 26: 751755.Google Scholar
52. Stieh, J, Fischer, G, Scheewe, J, et al. . Impact of preoperative treatment strategies on the early perioperative outcome in neonates with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2006; 131: 11221129.Google Scholar
53. Malagon, I, Onkenhout, W, Klok, G, van der Poel, PF, Bovill, JG, Hazekamp, MG. Gut permeability in paediatric cardiac surgery. Br J Anaesth 2005; 94: 181185.Google Scholar
54. Harrison, AM, Davis, S, Reid, JR, et al. . Neonates with hypoplastic left heart syndrome have ultrasound evidence of abnormal superior mesenteric artery perfusion before and after modified Norwood procedure. Pediatr Crit Care Med 2005; 6: 445447.Google Scholar
55. McElhinney, DB, Hedrick, HL, Bush, DM, et al. . Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes. Pediatrics 2000; 106: 10801087.Google Scholar
56. Wernovsky, G. Current insights regarding neurological and developmental abnormalities in children and young adults with complex congenital cardiac disease. Cardiol Young 2006; 16 Suppl 1: 92104.CrossRefGoogle Scholar
57. Kelleher, DK, Laussen, PC, Teixeira-Pinto, A, Duggan, C. Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure. Nutrition 2006; 22: 237244.Google Scholar