Catheterization for Congenital Heart Disease Adjustment for Risk Method (Charm)

Sedation and Anesthesia in Pediatric and Congenital Cardiac Catheterization: A Prospective Multicenter Experience

“…In addition, need for continuous supportive intravenous (IV) medications (including vasoactive and inotropic medications) and/or mechanical circulatory support including extracorporeal membrane oxygenation (ECMO) was also recorded. Indicators of hemodynamic vulnerability were developed previously by this group [4] and include low cardiac index, elevated systemic ventricle end diastolic pressure, low systemic arterial saturation, and elevated main PA systolic pressure (Supplemental Table 1B). Airway management for the procedure was recorded by the attending interventionalist as ''spontaneous respirations'' (natural airway with spontaneous ventilation), endotracheal intubation, laryngeal mask airway (LMA), or tracheostomy.…”

“…The Congenital Heart Disease Adjustment for Risk Model (CHARM) [4] was applied to examine the risk-adjusted relationship between management via intubation and the occurrence of any high-severity adverse events using logistic regression. In addition, the coefficients of each variable in the CHARM model were used to assign point values to each risk factor (procedure type risk category, number of hemodynamic indicators, age group, see Supplemental Table 1B and C); points were summed to obtain a risk score ranging from 0 to 8 for each subject, based on the patient's risk profile.…”

“…We could not, however, rule out the presence of confounders (higher complexity patients and procedures) associated with use of artificial airway strategy. Therefore, using factors that compose the CHARM model [4]: age, hemodynamic vulnerability (Supplemental Table 1B), and procedural complexity (Supplemental Table 1C), we developed a risk score to adjust for these factors and (Table 4). Further, in multivariable analysis adjusting for the variables included in the CHARM risk adjustment model, use of artificial airway remained a predictor for high-severity adverse events (Supplemental Table 3).…”

“…To this end, one of the major objectives of this study was to determine the risk of adverse events associated with strategy of procedural sedation with spontaneous respiration versus general anesthesia and managed airway. In comparing strategies, we employed CHARM [4] as a method to normalize risk in order to control for confounding factors associated with choice of airway management (i.e., ''sicker patients'' undergoing higher-risk procedures may be assigned artificial airway); however, artificial airway remained an independent predictor of high-severity adverse events and had a higher odds ratio for adverse events when compared with the same risk strata of patients managed by spontaneous respirations, findings further confirmed by propensity analyses. This higher rate of serious adverse events associated with artificial airway must be interpreted with caution, however, as we cannot exclude the possibility of unmeasured patient and procedural confounding characteristics or factors not accounted for by CHARM or propensity analysis.…”

“…Although guidelines from the American Society of Anesthesiology (ASA) and American Academy of Pediatrics (AAP) have been established for sedation of pediatric patients outside of the operating room setting [6], guidelines specific to the unique environment of the cardiac catheterization laboratory have not been proposed. Different modes of sedation and airway management directly impact measurements of cardiopulmonary physiology and additional challenges derived from significant heterogeneity in patients and complexity of transcatheter procedures [4]. This heterogeneity has resulted in significant differences in the approach to sedation and airway management for pediatric and congenital cardiac catheterizations between and within institutions.…”