Fast tracking after repair of congenital heart defects

Abstract

Fast tracking after repair of congenital heart defects (CHD) is a process involving the reduction of perioperative period by timely admission, early extubation after surgery, short intensive care unit (ICU) stay, early mobilisation, and faster hospital discharge. It requires a coordinated multidisciplinary team involvement. In the last 2 decades, many centres have adopted the fast tracking strategy in paediatric cardiac population, safely and successfully extubating patients in the OR with reported benefits in terms of reduced morbidity and ICU/hospital stay. In this manuscript, we will review the literature available on early extubation after repair of CHD and share our experience with this approach.

Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study*

“…We are unaware of other contemporary multicenter assessments that could confirm our finding that EE rates have not increased over the past decade regardless of age, surgical complexity, or center volume, but the consistency of this observation among all subgroups we evaluated supports its validity. This is despite many single-center and multicenter reports showing that EE is feasible in most postoperative cardiac patients, even in younger children with complex cardiac lesions (28–32), and a recent consensus statement from the American Association for Thoracic Surgery stating that EE is an “integral component” to enhance postoperative recovery in children (19).…”

The evolving role of dexmedetomidine in pediatric cardiac surgery: Beyond anxiolysis

“…9 One approach to this problem is to control the stress response with regional anesthesia while lowering the dose of intravenous narcotics. Garg et al 3 reported on a series of 1000 patients in which 40% of the neonates and 81% of the infants undergoing a variety of complex cardiac operations, including the Norwood procedure, were able to be extubated in the operating room. This was accomplished by limiting intravenous fentanyl to 5 µg/kg and using a single-shot caudal injection of morphine and DEX.…”

“…This was accomplished by limiting intravenous fentanyl to 5 µg/kg and using a single-shot caudal injection of morphine and DEX. 3 Likewise, Xu et al 6 used a reduced dose of sufentanil supplemented with ropivacaine peripheral nerve blocks to facilitate extubation in the operating room after cardiac surgery in infants, with an average extubation time of 22 min. 6 Maharramova performed a meta-analysis of the use of caudal anesthesia in congenital heart surgery.…”

“…This can place a particular strain on resource-limited healthcare systems. 3 These problems led to a renewed interest in earlier extubation while trying to avoid the consequences of inadequate control of the surgical stress response. 7 The retrospective study by Altun et al 8 in this recent issue presents a cohort study demonstrating the usefulness of the drug dexmedetomidine (DEX) in facilitating very early extubation following pediatric cardiac surgery.…”

“…2 High-dose fentanyl regimens for pediatric cardiac surgery became routine. Unfortunately, narcotic-induced respiratory depression resulted in prolonged postoperative intubation and ventilation 3 which has several negative effects. First, positive pressure ventilation can be disadvantageous in single-ventricle physiology.…”