Perioperative events in children with pulmonary hypertension undergoing non‐cardiac procedures

Abstract

Prior limited research indicates that children with pulmonary hypertension (PH) have higher rates of adverse perioperative outcomes when undergoing non-cardiac procedures and cardiac catheterizations. We examined a single-center retrospective cohort of children with active or pharmacologically controlled PH who underwent cardiac catheterization or non-cardiac surgery during 2006–2014. Preoperative characteristics and perioperative courses were examined to determine relationships between the severity or etiology of PH, type of procedure, and occurrence of major and minor events. We identified 77 patients who underwent 148 procedures at a median age of six months. The most common PH etiologies were bronchopulmonary dysplasia (46.7%), congenital heart disease (29.9%), and congenital diaphragmatic hernia (14.3%). Cardiac catheterizations (39.2%), and abdominal (29.1%) and central venous access (8.9%) were the most common procedures. Major events included failed planned extubation (5.6%), postoperative cardiac arrest (4.7%), induction or intraoperative cardiac arrest (2%), and postoperative death (1.4%). Major events were more frequent in patients with severe baseline PH (P = 0.006) and the incidence was associated with procedure type (P = 0.05). Preoperative inhaled nitric oxide and prostacyclin analog therapies were associated with decreased incidence of minor events (odds ratio [OR] = 0.32, P = 0.046 and OR = 0.24, P = 0.008, respectively), but no change in the incidence of major events. PH etiology was not associated with events (P = 0.24). Children with PH have increased risk of perioperative complications; cardiac arrest and death occur more frequently in patients with severe PH and those undergoing thoracic procedures. Risk may be modified by using preoperative pulmonary vasodilator therapy and lends itself to further prospective studies.

Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease

“…In a later retrospective series, an entirely pediatric population with different diagnostic categories was examined over an 8‐year period. PAH was secondary to bronchopulmonary dysplasia (BPD) in 46.8%, with only 28.6% was related to CHD.…”

“…It is possible these details are important factors in outcomes. The series reporting low complication rates in specialist centers indicate that the use of multidisciplinary decision‐making and planning and involvement of pediatric cardiac anesthetists are crucial to achieving these low rates …”

Current understanding and perioperative management of pediatric pulmonary hypertension

“…Children with PH have a significantly elevated risk of perioperative morbidity and mortality, with rates perhaps 20‐fold greater than all children undergoing anesthesia. Several pediatric studies have reported an incidence of perioperative cardiac arrest ranging from 0% to 5% and perioperative death up to 1.5% . However, defining precise risk stratification for anesthesia in the child with PH is problematic .…”

“…First, pediatric PAH is very uncommon, and thus the overall incidence of perioperative major morbidity and mortality is low. Second, most pediatric studies are retrospective and comparatively heterogeneous in regard to inclusion criteria, types of procedures and surgeries included, time frame inclusive of postoperative complications, changes to classification and management of pediatric PH over time, and institutional practice variation . Third, the various subgroups of pediatric PH may confer differing perioperative risk.…”

“…Data are lacking to delineate perioperative risk in the neonatal/infant PH population, predominantly those with PPHN or BPD‐PH. An exception is a recent study focusing on 77 infants with PH undergoing 148 procedures at a median of 6 months of age . The cohort included infants with BPD‐PH (50%), PAH‐CHD (30%), and CDH (14%; thus representing PPHN) undergoing cardiac and noncardiac procedures, including repair of CDH.…”