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Anesthesia for Pediatric and Congenital Cardiac Care

Gregory Lessans, MD, David F. Vener, MD
Anesthesia for Pediatric and Congenital Cardiac Care is a topic covered in the Adult and Pediatric Cardiac.

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Introduction

The development of reliable and safe pediatric cardiac anesthesia was developed hand in hand with that of pediatric cardiac surgery. The first ductal ligation at Boston Children’s Hospital by Dr. Robert Gross in 1938 was performed under cyclopropane anesthesia administered via a face mask by a skilled nurse anesthetist. Today, Pediatric Cardiac Anesthesiologists (PCA) utilize far more advanced – and invasive- ventilation and monitoring techniques that have led to a steady progression in the field and a dramatic reduction in both anesthesia and surgical mortality and morbidity. Today there are over 120 centers in the United States alone that provide advanced care for children with congenital heart defects. PCA providers deliver care in all areas of these hospitals: Cardiac Operating Rooms, General Operating Rooms on children with CHD, Cardiac Catheterization Laboratories, Radiology Suites, Intensive Care Units and more. In many of these hospitals the care is provided by a dedicated subset of physicians and nurse anesthetists who specialize in CHD, while in others either Pediatric Anesthesiologists or Adult Cardiac Anesthesiologists are responsible for the anesthetic management. In recent years there has been a significant push by leaders in the field to expand training as a Fellowship year in Pediatric Cardiac Anesthesia following an ACGME-accredited Pediatric Anesthesia Fellowship (or its equivalent).[1],[2],[3] In 2005, the Congenital Cardiac Anesthesia Society (CCAS) was established as a sub-specialty society under the auspices of the Society for Pediatric Anesthesia to facilitate education, collaboration, coordination with other societies around the world, quality and safety initiatives, research and data, training and advocacy and it serves as the primary focal point for providers in the U.S. and Canada.[4] Similar working groups, networks and societies exist around the world that specialize in this sub-specialized field of care.

PCA providers treat patients at all ages and stages, from the newborn with complex CHD requiring urgent surgery or catheter intervention to geriatric patients with newly discovered congenital heart defects that have only become symptomatic late in life or been discovered incidentally. As a consequence, PCAs must be facile in all aspects of anesthesia management of these challenging patients and procedures.

There are multiple textbooks and manuscripts that describe Pediatric Cardiac Anesthesia as a specialty and the landmark achievements that accompanied each stepwise improvement in treatment options. From the development of the heart-lung machine in the 1950s through the popularization of staged single ventricle palliation for Hypoplastic Left Heart Syndrome in the 1990s, to more recent efforts to elucidate and minimize the impact of general anesthesia on neurocognitive outcomes.[5],[6] None of this would have been possible without the active participation of PCA teams alongside the surgeons and researchers who worked to improve the safety and quality of the anesthesia and pre- and post-operative care of these patients. Regardless of these advances, this group of patients remains one of the most fragile and carries a significantly higher risk of anesthesia-related mortality and morbidity.

Ramamoorthy et al examined a subset of patients suffering cardiac arrest in children’s hospitals from 1994 through 2005 and determined that children with CHD were significantly sicker and, not surprisingly, far more likely to suffer a cardiac arrest than their non-CHD peers.[7] The CCAS collaboration with the Society of Thoracic Surgeons Congenital Heart Database has amassed a large body of data, including the incidence of anesthesia-related cardiac arrest, and has served as a starting point for studies involving medication usage, airway management, transfusion utilization and more.[8],[9],[10],[11] This dataset includes entries from over 60 centers located throughout the US and Canada performing more than 60% of cardiac bypass procedures in those countries. They document a cardiac arrest rate related to anesthesia care of 0.13% in patients undergoing cardiac surgery and an overall cardiac arrest rate (including related to surgical care) of 0.34%. Flick et al reported from the Mayo Clinic on the incidence of cardiac arrest in children from 1998 through 2005 and found an overall rate of 8.6 per 10,000 patients.[12] However, when separating out cardiac from non-cardiac patients they found an incidence of 127 per 10,000 patients in cardiac patients compared to 2.9 per 10,000 patients, a 40-fold increase in risk. A review of 5213 patients undergoing congenital heart surgery at Boston Children’s from 2000 through 2005 reported 41 arrests requiring cardiac compressions, and determined that 11 of 41 arrests were either related to or possibly-related to anesthesia management (21.1 per 10,000 anesthetics).[13] In their evaluation neonates were found to be at higher risk, but arrests associated with anesthesia did not appear to increase mortality.

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Introduction

The development of reliable and safe pediatric cardiac anesthesia was developed hand in hand with that of pediatric cardiac surgery. The first ductal ligation at Boston Children’s Hospital by Dr. Robert Gross in 1938 was performed under cyclopropane anesthesia administered via a face mask by a skilled nurse anesthetist. Today, Pediatric Cardiac Anesthesiologists (PCA) utilize far more advanced – and invasive- ventilation and monitoring techniques that have led to a steady progression in the field and a dramatic reduction in both anesthesia and surgical mortality and morbidity. Today there are over 120 centers in the United States alone that provide advanced care for children with congenital heart defects. PCA providers deliver care in all areas of these hospitals: Cardiac Operating Rooms, General Operating Rooms on children with CHD, Cardiac Catheterization Laboratories, Radiology Suites, Intensive Care Units and more. In many of these hospitals the care is provided by a dedicated subset of physicians and nurse anesthetists who specialize in CHD, while in others either Pediatric Anesthesiologists or Adult Cardiac Anesthesiologists are responsible for the anesthetic management. In recent years there has been a significant push by leaders in the field to expand training as a Fellowship year in Pediatric Cardiac Anesthesia following an ACGME-accredited Pediatric Anesthesia Fellowship (or its equivalent).[1],[2],[3] In 2005, the Congenital Cardiac Anesthesia Society (CCAS) was established as a sub-specialty society under the auspices of the Society for Pediatric Anesthesia to facilitate education, collaboration, coordination with other societies around the world, quality and safety initiatives, research and data, training and advocacy and it serves as the primary focal point for providers in the U.S. and Canada.[4] Similar working groups, networks and societies exist around the world that specialize in this sub-specialized field of care.

PCA providers treat patients at all ages and stages, from the newborn with complex CHD requiring urgent surgery or catheter intervention to geriatric patients with newly discovered congenital heart defects that have only become symptomatic late in life or been discovered incidentally. As a consequence, PCAs must be facile in all aspects of anesthesia management of these challenging patients and procedures.

There are multiple textbooks and manuscripts that describe Pediatric Cardiac Anesthesia as a specialty and the landmark achievements that accompanied each stepwise improvement in treatment options. From the development of the heart-lung machine in the 1950s through the popularization of staged single ventricle palliation for Hypoplastic Left Heart Syndrome in the 1990s, to more recent efforts to elucidate and minimize the impact of general anesthesia on neurocognitive outcomes.[5],[6] None of this would have been possible without the active participation of PCA teams alongside the surgeons and researchers who worked to improve the safety and quality of the anesthesia and pre- and post-operative care of these patients. Regardless of these advances, this group of patients remains one of the most fragile and carries a significantly higher risk of anesthesia-related mortality and morbidity.

Ramamoorthy et al examined a subset of patients suffering cardiac arrest in children’s hospitals from 1994 through 2005 and determined that children with CHD were significantly sicker and, not surprisingly, far more likely to suffer a cardiac arrest than their non-CHD peers.[7] The CCAS collaboration with the Society of Thoracic Surgeons Congenital Heart Database has amassed a large body of data, including the incidence of anesthesia-related cardiac arrest, and has served as a starting point for studies involving medication usage, airway management, transfusion utilization and more.[8],[9],[10],[11] This dataset includes entries from over 60 centers located throughout the US and Canada performing more than 60% of cardiac bypass procedures in those countries. They document a cardiac arrest rate related to anesthesia care of 0.13% in patients undergoing cardiac surgery and an overall cardiac arrest rate (including related to surgical care) of 0.34%. Flick et al reported from the Mayo Clinic on the incidence of cardiac arrest in children from 1998 through 2005 and found an overall rate of 8.6 per 10,000 patients.[12] However, when separating out cardiac from non-cardiac patients they found an incidence of 127 per 10,000 patients in cardiac patients compared to 2.9 per 10,000 patients, a 40-fold increase in risk. A review of 5213 patients undergoing congenital heart surgery at Boston Children’s from 2000 through 2005 reported 41 arrests requiring cardiac compressions, and determined that 11 of 41 arrests were either related to or possibly-related to anesthesia management (21.1 per 10,000 anesthetics).[13] In their evaluation neonates were found to be at higher risk, but arrests associated with anesthesia did not appear to increase mortality.

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Last updated: February 17, 2021