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Fast-tracking with continuous thoracic epidural analgesia in paediatric

congenital heart surgeries: an institutional experience

Article in Indian Journal of Thoracic and Cardiovascular Surgery · May 2022

DOI: 10.1007/s12055-022-01373-8

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Indian Journal of Thoracic and Cardiovascular Surgery
https://doi.org/10.1007/s12055-022-01373-8

ORIGINAL ARTICLE

Fast‑tracking with continuous thoracic epidural analgesia in paediatric

congenital heart surgeries: an institutional experience
Alok Kumar1 · H. R. Ramamurthy2 · Nikhil Tiwari3 · Saajan Joshi1 · Gaurav Kumar3 · Vivek Kumar2 · Vipul Sharma4

Received: 27 January 2022 / Revised: 27 April 2022 / Accepted: 28 April 2022

© Indian Association of Cardiovascular-Thoracic Surgeons 2022

Abstract
Objective To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under
general anaesthesia with continuous thoracic epidural analgesia (TEA).
Methodology It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12 years or younger, were
operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71
patients, data from the remaining 390 patients were analysed.
Measurements and main results The median time for extubation after intensive care unit admission was 2 h and 25 min
(0–20 h). Extubation within 6 h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly
shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004) than patients in the ventilated group. Reintubation was required in
27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively
and cardiopulmonary bypass time > 90 min significantly predicted failure in fast-tracking with an odds ratio (OR) = 1.27;
CI: 1.18–1.38 and OR = 2.3; CI: 1.8–2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-
Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic
score did not adversely affect early extubation, contrary to contemporary concerns.
Conclusions A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine
infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data sug-
gests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric
cardiac surgery.

Keywords Congenital heart surgery · Congenital heart disease · Fast-tracking · Thoracic epidural analgesia

Introduction safely undergo congenital heart surgery. The increase in

the number of cases, as well as the complexity of cases,
The surgical management of congenital heart diseases has increased the duration and cost of perioperative care.
(CHDs) in children has seen rapid advances in recent Fast-tracking is a multidisciplinary approach conceptualised
years. This has enabled a greater number of children to to reduce the length of post-operative hospitalisation. The
entire process of fast-tracking and early recovery of patients
starts intraoperatively and extends to the intensive care unit
* Alok Kumar
docsomi@yahoo.com (ICU). The rate-limiting step in fast-tracking is early post-
operative extubation and they are almost synonymous with
1
Department of Anaesthesia & Critical Care, Army Hospital the goal to achieve shorter hospital stay and improved out-
(Research & Referral), Delhi Cantt, New Delhi 110010, comes [1]. The definition of fast-tracking has been variable,
India
but the goal of every protocol is safe early extubation, either
2
Department of Paediatrics, Army Hospital (Research & in the operating room or within a few hours of admission
Referral), Delhi Cantt, New Delhi 110010, India
to the ICU. We have defined ‘fast-tracking ’ as extubation
3
Department of Cardiothoracic Surgery, Army Hospital within 12 h of surgery with no reintubation. Fast-tracking
(Research & Referral), Delhi Cantt, New Delhi 110010, India
has been practised in the surgical management of CHD [2–5]
4
Department of Anaesthesia & Critical Care, Dr. DY Patil
Medical College, Pune, India

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 Indian Journal of Thoracic and Cardiovascular Surgery

with neuraxial analgesia being an integral part of the process injection vecuronium at 0.1 mg/kg/h. After intubation, a 19G
in some institutes [2–4, 6–9]. epidural catheter (M/s Smiths medical, Czech Republic) was
The neuraxial analgesic technique with opioids provides placed preferably at T6-7 space by trained cardiac anaesthe-
effective and prolonged analgesia and blunts the stress siologists, using the ‘loss of resistance’ technique, with the
response to surgery [10]. Advantages like decreased com- patient in left lateral position. Bolus of 1 mL/kg of 0.25%
plication rates such as cardiovascular events, respiratory bupivacaine with 50 µg/kg morphine was administered, in
complications, acute kidney injury and sepsis, as well as a two divided doses 30 min apart, in the epidural catheter,
shorter ICU stay, lower cost of anaesthesia and earlier hos- followed by an infusion of 0.125% bupivacaine at the rate of
pital discharge, are well documented with the high thoracic 0.1 mL/kg/h throughout the intraoperative period. Dexme-
epidural technique [11]. The incorporation of dexmedeto- detomidine was started intraoperatively at a rate of 0.25 µg/
midine, propofol and shorter acting opioids has also given kg/h and continued in the postoperative period until 12 h
fast-tracking a new dimension. This study was carried out post extubation, up to a maximum of 48 h.
with the primary objective of assessing the incidence of Cardiopulmonary bypass (CPB) with ultrafiltration was
successful fast-tracking in paediatric cardiac surgery using performed according to our institutional protocol (see Sup-
thoracic epidural analgesia (TEA). Secondary objectives plementary Material). Milrinone was started with a loading
included assessment of the causes of failure of fast-tracking, dose of 100 µg/kg at the release of the aortic cross clamp
mechanical ventilation duration and length of hospital stay. (ACC) and an infusion of milrinone at a dose of 0.75 µg/kg/
Fast-tracking using TEA is the standard of care in our insti- min was maintained thereafter, if pulmonary arterial hyper-
tution, and therefore, study population was not randomised. tension (PHT) or severe ventricular dysfunction was pre-
sent perioperatively. Preoperative PHT was assessed using
echocardiography and cardiac catheterization in a few cases.
Material and methods Post CPB, in the operating room, PHT was established with
needle pressure of main pulmonary artery, while postopera-
This is an institutional ethical committee–approved retro- tive in ICU it was measured using echocardiography.
spective cohort study (CTRI Reg No CTRI/2022/01/039585). Perioperative goal-oriented haemodynamic support (i.e.,
Over a 2-year period from January 2018 to December 2019, heart rate and mean arterial pressure at 95 percentiles for
461 children, aged 12 years or younger, were operated for age, central venous pressure as per the CHD, taking into
congenital heart disease. After the exclusion of 71 patients, account mechanical ventilation at positive end-expiratory
the data from the remaining 390 patients were analysed. pressure of 4 to 5 cm H ­ 2O, mixed venous oxygen satura-
Also, patient data was extracted from the clinical data- tion > 65%) was established according to the institutional
base without any additional questionnaires. Children were protocol. Haematocrit was maintained at more than 35%
excluded if they had evidence of preoperative sepsis or were in all acyanotic patients and more than 40% in cyanotic
on mechanical ventilation before surgery, on extracorpor- patients. Extubation was decided by the anaesthesiologist as
eal membrane oxygenation (ECMO) perioperatively, or per the extubation criteria (Fig. 2). Post-operative analgesia
patients who were never extubated and died in post-operative in the ICU was maintained with continuous epidural infu-
period. None of our patients were on anticoagulants, and sion of 0.125% bupivacaine at the rate of 0.1 mL/kg/h, and
any patients on soluble aspirin were stopped 2 days prior fentanyl boluses of 1 µg/kg were used as rescue analgesia.
to surgery. All 390 patients were planned to be managed Pain was assessed using a three-point face, leg, activity, cry
under the fast-track protocol (Fig. 1). Some patients who and consolability (FLACC) scale [12] scored from 0 to 10,
were extubated on arrival in the ICU would have qualified and rescue analgesia was given when the score was more
for extubation in the operating room, but owing to time and than 6. The epidural catheter was removed 72 h after surgery.
staffing constraints, they were shifted to the ICU intubated, After extubation, oxygen was administered to the patient
but breathing spontaneously. via a high-flow nasal cannula (HFNC) device with a dis-
The anaesthetic technique was as per standard institu- posable wide-bore snugly fitting nasal cannula of various
tional protocol, i.e., general anaesthesia (GA) with TEA. sizes for children of various ages (AIRVO2® with Optiflow
All patients were taken into the operating room pre-med- Junior nasal prong®, Fisher & Paykel Healthcare Limited,
icated with intranasal ketamine 7 mg/kg and nasal mida- Auckland, New Zealand). This device was capable of deliv-
zolam 0.3–0.5 mg/kg. Induction was done with 2 mg/kg ering flow rates of up to 25 L/min in paediatric mode. We
intravenous (IV) ketamine supplemented with 2 µg/kg IV applied a flow rate of 2 L/kg and a ­FiO2 of 0.6 initially, with
fentanyl, and IV rocuronium 1 mg/kg was administered to subsequent adjustments being carried out as guided by the
assist oral endotracheal intubation. Anaesthesia was main- clinical condition and arterial blood gas analysis.
tained with sevoflurane at 0.6–2% with oxygen and air mix- Echocardiography and cardiac catheterization reports,
ture (inspired oxygen concentration (­ FiO2) of 0.5–0.6) and operative notes, anaesthesia notes, perfusion charts and ICU

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Indian Journal of Thoracic and Cardiovascular Surgery

Fig. 1  Fast-track protocol

FAST TRACK PROTOCOL: PAEDIATRIC CARDIAC SURGERY

AIM:
• Early tracheal extubation (<12h)
• Reduced postoperative complications
• Reduced ICU and hospital stay

PRE-OPERATIVE STRATEGY:

1. Avoiding prolonged pre-operative fasting:

Neonates and infants <6 months-breast milk given till 4 hours preoperatively
Clear fluids permitted till 2 hours preoperatively
2. Skin disinfection: 2% Chlorhexidine body wipe (avoid mucosal surface) 24 and 2 hours
before surgery.
3. Preoperative echocardiography discussion with the team.
4. Counselling of older children and parents

INTRAOPERATIVE STRATEGY:

1. Intranasal ketamine and midazolam as premedication: For smooth induction and as part of
multimodal analgesia initiation.
2. Intravenous antibiotics (third generation cephalosporin: cefoperazone + sulbactam) one hour prior to
surgical incision.
3. Epidural analgesia (indwelling catheter to reduce stress response and for analgesia)
4. Dexmedetomidine + Propofol infusion started intraoperatively to reduce agitation in the postoperative
period and help in early extubation.
5. Balanced anaesthesia technique with no high dose opioid. Neuraxial opioid given.
6. Goal directed fluid therapy. (Fluids prepared as per age and requirement of each child)
7. Use of tranexamic acid in all, preoperative acute normovolumic haemodilution when Haematocrit>50%,
Goal directed transfusion
therapy using Sonoclot (Sienco®, Inc, USA) and Thrombelastography guided.
8. Conventional and modified ultrafiltration in all cases for fluid and haematocrit optimisation and
removal of inflammatory cytokines.

POSTOPERATIVE STRATEGY:

1. Swarming in technique for receiving patient from Operation Theatre.

2. Post extubation high flow nasal cannula (AIRVO2®, Fischer & Paykel Healthcare, New Zealand)
with Optiflow junior nasal cannula of appropriate sizes) in all cases.
3. Target controlled glucose management.
4. Active temperature management (Intraoperative and postoperative)
5. Epidural analgesia for 72 hours.
6. Dexmedetomidine + Propofol sedation for 12 hours post extubation titrated to clinical effects.
(For prolonged mechanical ventilation change to fentanyl and midazolam)
7. Trophic feeds in neonates at 2 ml/kg/hr through nasogastric tube started 1-hour post-surgery if no
contraindications. Transition to full feeds 4 hours post extubation.
8. Ultrasonic nebulisation and chest physiotherapy 4 hourly in all cases.
9. Early mobilisation and Tri-cycling in older children.
10. Involvement of parents in child care to promote bonding in neonates and infants.
11. Early removal of arterial line and central venous catheters.
12. No antibiotics after 3 doses unless protocol violation indicated.

nursing charts were reviewed along with case notes for the data Statistical analysis The distribution of the continuous data was
collection. The inotropic requirement was assessed in terms tested with the Kolmogorov–Smirnov test. Continuous data are
of vasopressor inotropic score (VIS) using the formula [13]: reported as mean ± standard deviation, and dichotomous data
are expressed as numbers and percentages. Continuous vari-
VIS = dopamine(𝜇g∕kg∕min) + dobutamine(𝜇g∕kg∕min) ables showing skewed distributions were described as median
with interquartile range (IQR). Comparison between the groups
+ 100 × epinephrine(𝜇g∕kg∕min)
was carried out using unpaired student’s t-test or chi-square con-
+ 10 × milrinone(𝜇g∕kg∕min) tingency tables. Univariate analysis was performed using the
+ 10, 000 × vasopressin(IU∕kg∕min) Mann–Whitney U test, and logistic regression analysis was per-
+ 100 × norepinephrine(𝜇g∕kg∕min). formed to predict failure in fast-tracking. Receiver operating

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 Indian Journal of Thoracic and Cardiovascular Surgery

Fig. 2  Extubation criteria

1. No significant residual defect as established by trans-esophageal/epicardial

echocardiography.

2. Appropriately warmed to a temperature of >35 degree Celsius.

3. Adequate reversal of muscle paralysis as assessed by facial grimace, eye opening,

spontaneous tidal volume greater than 5.5 ml/kg, purposeful movement, movement other

than coughing.

4. Absence of pulmonary bleed, able to maintain ETCO2 < 45 mm Hg on minimum pressure

support with optimal respiratory rates per age (<30-45 per minute), able to maintain

adequate oxygen saturation as per lesion and RSBI ≤ 8 breaths/min/ml/kg body weight.

5. Haemodynamics maintained on minimum ionotropes (VIS < 20) and Hct 35-40% with no

obvious clinical bleed.

6. Absence of arrhythmia, electrolyte disturbance and acidosis (pH < 7.25)

characteristic (ROC) curve was utilised to find cutoff value

of CPB time for predicting failure of fast-tracking. Statistical
analysis was performed using SPSS software (IBM SPSS
Statistics version 21, Chicago IL, USA). A p-value of less
than 0.05 was considered statistically significant.

Observations and results

Data of all the patients who underwent surgery for CHD

from January 2018 to December 2019 was analysed.
Among the 461 patients who underwent surgery for CHD
during this period, 71 were excluded. Out of 390 patients
included for the retrospective analysis, 360 patients under-
went surgery under CPB and 30 patients without CPB.
Figures 3 and 4 show case distributions based on diagnosis
and procedures.
The enrolled patients were divided as per STAT (the
Society of Thoracic Surgeons-European Association for
Cardio-Thoracic Surgery Congenital Heart Surgery) mor-
tality categories based on the diagnosis and the surgi-
cal procedure they underwent. The STAT score is a tool
designed to analyse the risk of mortality associated with Fig. 3  Consort
congenital heart surgery procedures [14]. All children
underwent similar sedation and analgesia protocols both
intra- and postoperatively.

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Indian Journal of Thoracic and Cardiovascular Surgery

Fig. 4  Groups showing case Gp No Diagnosis and Procedures No %

distributions based on diagnosis
and procedures
1 Left to right shunt - Complex (AVCD, DORV, COMPLEX VSD) 35 9
2 Left to right shunt - Simple (ASD, VSD, PDA, Partial AVCD) 187 48
3 Right to left shunt (TOF, DORV VSD PS, TGA, TA, EBSTEIN, TAPVC) 96 24.6
4 Isolated Non Valvular Obstructive lesions (RVOTO) 4 1
5 Valvular lesions (Aortic, Mitral: Stenotic and regurgitant) 11 2.8
6 Palliative Surgeries (mBTS, Glenn/Fontan) 39 10
7 Aortic pathologies (Coarctation of aorta, Hypoplastic Arch) 18 4.6
TOTAL 390
AVCD Atrioventricular canal defect, DORV Double outlet right ventricle, VSD Ventricular septal defect, ASD Atrial septal defect, PDA
Patent ductus arteriosus, TOF Tetralogy of Fallot, PS Pulmonary stenosis, TGA Transposition of great vessels, TA Truncus arteriosus,
TAPVC Total anomalous pulmonary venous connection, RVOTO Right ventricle outlet tract obstruction, mBTS modified Blalock-
Taussig Shunt.

Preoperative factors 47.7 ± 30.9 min, n = 236 and 234, respectively), p < 0.001.
All patients underwent post-operative epicardial echocardi-
Preoperative and intraoperative characteristics of the patients ography or trans-oesophageal echocardiography. Thirteen
are presented in Table 1. The median age of the patients patients required revision and underwent a second CPB run.
was about 15 months (IQR 5.7–60) and the male-to-female Mean lowest temperature during the procedure was 32 °C
ratio was 1.16:1 (210:180). Cyanotic patients (n = 135) com- (Table 1).
ing for corrective or palliative surgeries and patients with
coarctation of the aorta/hypoplastic aortic arch (n = 16) Fast‑tracking
were predominantly neonates and infants (66.2%). Eighty-
seven patients (22.3%) had moderate to severe PHT, while Early extubation and fast-tracking could be practised in
94 (24.1%) had congestive cardiac failure (CCF) preopera- only 232 out of the 390 patients, among whom two got
tively. Twenty-two patients had associated co-morbidities, reintubated. Therefore, the success of the fast-track pro-
among which Down syndrome was the commonest (n = 14) tocol was finally in 230 patients (59%). The median time
followed by Turner syndrome (n = 2), Williams syndrome to achieve tracheal extubation after admission to the ICU
(n = 2), 22q11.2 deletion (n = 3) and Noonan syndrome in the study population was 2 h and 25 min (0–20 h),
(n = 1). with the longest being 960 h. The goal of extubation
within 6 h was achieved in 215 patients (~ 55%). Seven-
Intraoperative factors teen patients were extubated between 6 and 12 h post-
operatively. Eighty-one patients remained intubated for
The mean CPB time was 95 ± 57 min and the ACC time was 12 to 24 h and 13 had long-term ventilation (> 2 weeks)
59 ± 38 min. The mean CPB and ACC time in cyanotic CHD (Table 2).
was longer (130.7 ± 64.8 and 83.2 ± 41.5 min; n = 123 and Sixty-four patients remained on ventilator for more
106, respectively) than in acyanotic CHD (76.6 ± 42.7 and than 24 h. The commonest causes were low cardiac output

13
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Table 1  The distribution of patients demographic data, anthropometric data, co-morbidities, preoperative laboratory investigations and relevant intraoperative data of the patients. IQR inter
quartile range, BSA body surface area, PHT pulmonary hypertension, CCF congestive cardiac failure, ACC​cross clamp time, CPB cardio pulmonary bypass time
Age Sex ratio Weight (kg) BSA PHT CCF Co-mor- ACC (min- CPB 2nd CPB Hypother- Nadir tem- No CPB
(months) (square bidity utes) (minutes) mia with perature
metre) low flows
STAT n (%) Median (Male:female) Median Median n (%) n (%) n (%) Mean ± SD Mean ± SD n (%) n (%) Mean ± SD n (%)
category (IQR) (IQR) (IQR)

1 177 14.9 90:87 9 0.4 35 (19.8%) 37 (20.9%) 11 (6.2%) 58.7 ± 38.3 95.2 ± 57.3 2 (1.1%) 0 32.0 ± 3.4 1 (0.6%)
(45.4%) (5.7–60) (5.2–17) (0.3–0.7)
2 102 19.9 54:48 10 0.41 24 (23.5%) 30 (29.4%) 6 (5.9%) 60.6 ± 32 91 ± 43 3 (2.9%) 1 (0.9%) 33.5 ± 2.45 12 (11.8%)
(26.2%) (6.8–84) (5.6–20) (0.3–0.8)
3 27 (6.9%) 11.5 13:14 6.9 0.37 3 (11.1%) 9 (33.3%) 1 (3.7%) 92.7 ± 40.9 156 ± 71.3 1 (3.7%) 0 30 ± 3.4 2 (7.4%)
(3–18) (3.5–15.3) (0.2–0.67)
4 82 (21%) 4.4 51:31 5.2 0.3 25 (30.5%) 18 (21.9%) 4 (4.9%) 82.1 ± 44.6 136.1 ± 69.1 7 (8.5%) 3 (3.7%) 32.3 ± 3.9 15 (18.3%)
(1.4–13) (3.4–8.8) (0.21–0.37)
5 2 (0.5%) 27.5 2:0 9.75 0.43 0 0 0 107.5 ± 37.5 169 ± 84.8 0 2 (40%) 27 ± 1.4 0
(12, 43) (9, 10.5) (0.35, 0.51)
TOTAL 390 14.9 210:180 9 0.41 87 (22.3%) 94 (24.1%) 22 (5.6%) 58.7 ± 38.2 95.2 ± 57.3 13 (3.3%) 6 (1.5%) 31.9 ± 3.5 30 (7.7%)
(5.7–60) (5.2–17) (0.29–0.7)
Indian Journal of Thoracic and Cardiovascular Surgery
Indian Journal of Thoracic and Cardiovascular Surgery

Table 2  The distribution of the study population according to the time taken for tracheal extubation in different STAT (the Society of Thoracic
Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery) categories
STAT category
Extubation time (h) 1 2 3 4 5 Total Chi-square value P value
n (%) n (%) n (%) n (%) n (%) n (%)

0h 102 (57.6%) 56 (54.9%) 5 (18.5%) 9 (11%) 0 174 (44.6%) 146.8 < 0.0001
0–6 h 19 (10.7%) 8 (7.8%) 3 (11.1%) 10 (12.2%) 1 (50%) 41 (10.5%) 12.8 0.005
> 6 h–12 h 5 (2.8%) 2 (1.96%) 4 (14.8%) 6 (7.3%) 0 17 (4.4%) 4.8 0.2
> 12 h–24 h 37 (20.9%) 22 (21.6%) 3 (11.1%) 18 (22%) 1 (50%) 81 (20.8%) 29.3 < 0.0001
> 24 h 13 (7.3%) 11 (10.8%) 9 (33.3%) 31 (37.8%) 0 64 (16.4%) 37.5 < 0.0001
Died on mechanical ventilation 1 (0.56%) 2 (1.96%) 2 (7.4%) 8 (9.8%) 0 13 (3.3%) 17 0.001
Total 177 (45.4%) 102 (26.2%) 27 (6.9%) 82 (21%) 2 (0.5%) 390 131.8 < 0.001

STAT​The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery

Table 3  The distribution of patients according to the indications for bleeding required re-exploration. No adverse effects from
reintubation after early extubation after cardiac surgery reintubation occurred in these patients.
Indication of reintubation Number
of patients ICU factors
(%)

Bleeding* 1 (3.7%) The mean consumption of fentanyl for pain relief

Bronchomalacia/tracheomalacia/airway obstruction 4 (14.8%) in the ICU was 0.62 ± 0.3 mcg/kg in the first 24 h
Septic shock/ARDS 5 (18.5%) (n = 69; 17.7%) and only in 4 patients on the second
Congested lung due to ischemic reperfusion injury/ 3 (11.1%) postoperative day. The average VIS score in the ICU
residual lesion, palliative surgery on admission postoperatively was 12.3 ± 8.8, with
Low cardiac output (LV/RV dysfunction) and/or severe 10 (37%) patients in STAT category-5 having the highest VIS
PHT score (Table 4). The median length of stay (LOS)
Diaphragmatic palsy 2 (7.4%) in hospital for all children who survived was 6 days
Arrhythmia (leading to low cardiac output state) 2 (7.4%) (IQR 5–9 days), with the longest stay being 106 days.
TOTAL 27 (6.9%) Patients in the early extubation group had significantly
*
Requiring transfusion or draining > 10 ml/kg in 4 h; ARDS acute res-
shorter LOS (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004)
piratory distress syndrome, LV left ventricle, RV right ventricle, PHT than patients in the ventilated group. Table 4 summa-
pulmonary hypertension rises the groups’ postoperative outcomes and compli-
cations. One patient, who underwent surgery for hypo-
plastic aortic arch under low flows in hypothermia, had
syndrome due to ventricular dysfunction or severe post-CPB postoperative focal seizures that were managed con-
PHT, followed by other causes like lung congestion and servatively with no neurological sequel. Culture-posi-
severe sepsis, which manifested at different time periods in tive sepsis was seen in 48 (12.3%) patients, which was
the ICU. The patients who remained intubated for more than managed with antibiotics as per the sensitivity pattern.
3 days had one or more of the following causes: postopera- All-cause 30-day mortality was 3.3% (n = 13), with half
tive phrenic nerve injury with resultant hemi-diaphragmatic of them being patients with complex cyanotic heart dis-
paralysis, sepsis, pneumonia/acute respiratory distress syn- ease undergoing corrective surgery. Thirteen patients
drome, bronchomalacia, or tracheomalacia. died after surgery while still on mechanical ventilation
for varying lengths of time. They had prolonged CPB
time, and ACC time, and suffered from low cardiac
Reintubation output/acute kidney injury postoperatively.
No significant adverse effects were noted related to
Reintubation was required in 27 (6.9%) patients, and the rea- TEA. No intravascular or intrathecal puncture occurred
sons for reintubation are enumerated in Table 3. All patients during the placement of the thoracic epidural catheter.
with hemi-diaphragmatic palsy were managed with surgi- Neither pruritis nor urinary retention were noted in any
cal diaphragmatic plication. One patient with postoperative of the cases. This could be attributable to sedation post

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 Indian Journal of Thoracic and Cardiovascular Surgery

Table 4  Intensive Care Unit complications and outcomes in respective STAT categories
STAT category n (%) Reintubation Sepsis PD/AKI Heart Bleeding/ MV dura- LOS (days) Mortality
n (%) n (%) n (%) block/ re-explora- tion (hours) excluding n (%)
arrhythmia tion (excluding mortality
n (%) n (%) mortality) Median (IQR)
Median (IQR)

1 177 (45.4%) 3 (1.7%) 8 (4.5%) 4 (2.3%) 4 (2.3%) 0 0 (0–17.3) 5 (5–7) 1 (0.6%)

2 102 (26.2%) 4 (3.9%) 13 (12.7%) 2 (1.96%) 3 (2.9%) 0 0 (0–18) 6 (5–8) 2 (1.96%)
3 27 (6.9%) 8 (29.6%) 10 (37%) 8 (29.6%) 3 (11.1%) 1 (3.7%) 19 (0–139.5) 11 (6–22.5) 2 (7.4%)
4 82 (21%) 11 (13.4%) 16 (19.5%) 14 (17.1%) 5 (6.1%) 1 (1.2%) 24 (14–91) 9 (6–17) 8 (9.8%)
5 2 (0.5%) 1 (50%) 1 (50%) 0 0 0 306 (12,600) 25 (9, 41) 0
TOTAL 390 27 (6.9%) 48 (12.3%) 28 (7.2%) 17 (4.4.%) 23 (5.9%) 2.25 (0–20) 6 (5–9) 13 (3.33%)

IQR interquartile range, VIS Vassopressor-Ionotropic Score, LOS length of hospital stay, MV mechanical ventilation, ICU intensive care unit,
PD/AKI peritoneal dialysis/acute kidney injury

extubation in the ICU and also that the patients’ bladders patients. Propofol and dexmedetomidine are successfully
were catheterized for 3–4 days after the surgery. being employed perioperatively in children undergoing sur-
gery for CHD with obvious clinical benefits [15, 16]. We use
Failure of fast‑tracking minimal infusion doses of both to achieve a balance between
keeping the child calm (with all lines and tubes in situ) and
A logistic regression analysis was run to predict the risk avoiding any respiratory and haemodynamic compromise
factors for failure in fast-tracking. CPB time and nadir tem- at the same time.
perature intra-operatively significantly predicted failure
in fast-tracking of the patients, F (8,301) = 13.91, p < 0.0001; Thoracic epidural and fast‑tracking
R2 = 0.27 (Table 5). Patients with a low nadir temperature
intraoperatively, who could not be extubated early, had an The benefit of neuraxial technique in a fast-track protocol
odds ratio (OR) = 1.27; CI: 1.18–1.38. The CPB cutoff time is that it minimises the use of high-dose intravenous opioid
for predicting fast-tracking failure from the ROC curve was administration. Cardiac surgery requires a sensory block
90 min, with 72% sensitivity and 75% specificity (Fig. 5). from the first thoracic dermatome level (T1) downward and
Patients with a CPB time of more than 90 min who could not a complete sympathectomy, which includes cardiac sympa-
be extubated early had an OR of 2.3, CI: 1.8–2.96. thectomy. This can be satisfactorily achieved with neuraxial
anaesthesia. The successful use of single-shot intrathecal or
caudal morphine with or without local anaesthetic as well
Discussion as the insertion of thoracic epidural catheters in children has
been reported [2, 4, 9]. It not only provides superior analge-
The care of paediatric cardiac surgical patients involves a sia, but epidural or intrathecal opioids have been shown to
set of sequential actions leading them from admission to blunt the stress response to surgery and CPB. It also leads
safe discharge. The rate-limiting step in this process is the to shorter mechanical ventilation duration with improved
duration of post-operative mechanical ventilation. Paediatric pulmonary function, and all of this reduces resource utilisa-
cardiac surgery has been associated with high doses of opi- tion in the hospital and ICU [1]. Fast-tracking of paediatric
oid-based anaesthesia mandating prolonged post-operative cardiac patients can be achieved safely with the help of mod-
mechanical ventilation. Therefore, to reduce the duration of ern short-acting opioids without neuraxial anaesthesia. How-
post-operative ventilation, it is necessary to rationalise the ever, the short-acting opioid remifentanil, which allows for a
dose of opioid while ensuring analgesia and sedation. Previ- ‘high-dose opioid’ technique without the need for prolonged
ously, all patients did not receive TEA and a high opioid- mechanical ventilation, may not be available everywhere.
based protocol with prolonged ventilation was followed in Although TEA in paediatric cardiac surgery remains con-
paediatric cardiac surgery at our institute. With an increas- troversial, we favoured TEA over intrathecal analgesia as the
ing number of surgeries and limited resources, our centre clinical effects of intrathecal analgesia are variable and also
has established a protocol to achieve adequate perioperative lead to greater respiratory depression. The additional advan-
pain relief and sedation with early extubation (Fig. 1). We tages of continuous TEA are selective segmental anaesthesia
employ a propofol and dexmedetomidine-based regimen in and the absence of motor blockade. The infusion is better
addition to continuous TEA successfully in fast-tracking of than the single-shot technique as it allows better control over

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 Table 5  The distribution of the factors that predict failure to fast-tracking in the study population excluding the mortality
Univariate* Multivariate
#
Parameters Z /chi-square p-value OR 95% CI p-value
Indian Journal of Thoracic and Cardiovascular Surgery

PHT 4.17 0.05 1.1 0.98–1.3 0.06

Age (months) 63.13 < 0.0001 0.99 0.98–1.0 0.35
Weight (kg) 70.98 < 0.0001 1.0 0.95–1.07 0.77
BSA (square metre) 73.94 < 0.0001 1.1 0.8–1.9 0.07
STAT score − 6.01# < 0.0001 STAT 1 0.29 0.01–5.7 0.06
STAT 2 0.26 0.01–5.1
STAT 3 0.43 0.02–9.2
STAT 4 0.09 0.004–1.8
STAT 5 0.05 0.002–1.1
ACC (minutes) 37.54 < 0.0001 1.0 0.98–1.01 0.86
CPB (minutes) 48.74 < 0.0001 2.3 1.8–2.96 0.03
Nadir temperature 42.05 < 0.0001 1.27 1.18–1.38 0.002
(degree Celsius)
VIS 10.44 0.001 1.0 0.97–1.03 0.95

*Mann-Whitney U test, p < 0.05 significant

OR odds ratio, CI confidence interval, PHT preoperative pulmonary hypertension, BSA body surface area, STAT​ The Society of Thoracic Surgeons-European Association for Cardio-Thoracic
Surgery, ACC​aortic cross clamp time, CPB cardiopulmonary bypass time, VIS Vassopressor Ionotropic Score

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 Indian Journal of Thoracic and Cardiovascular Surgery

temperature intraoperatively and long CPB time were inde-

pendent contributing factors in late extubation (OR = 3.2 and
2.3 respectively). PHT has been reported as a risk factor for
prolonged mechanical ventilation [18, 19]. Post CPB PHT
has been considered more significant than preoperative PHT
as a risk factor for prolonged mechanical ventilation in chil-
dren undergoing CHD surgery [2, 20]. In our analysis, we
only considered preoperative PHT and employed milrinone
infusion in all such cases immediately after induction. Com-
plex procedures require longer CPB time. However, no asso-
ciation of STAT score with the time period of extubation
could be established; we had only 2 cases in the STAT 5 cat-
egory, which is an obvious limitation. Hence, the inability to
Area=0.74
fast-track could not be solely attributed to the complexity of
P<0.001
the surgery. Although neonates were few in our studies, but
46.5% of our patients included infants. Keeping this in mind,
we found that younger age or less weight did not adversely
impact early extubation in our study. This is an interesting
observation since it is contrary to the experience of a few
other workers who were apprehensive about early extuba-
Fig. 5  ROC (receiver operating characteristic) curve tion in this subset of patients [3]. Heinle et al. also showed
that successful early extubation is possible in all age groups,
including neonates, similar to our study [4].
anaesthesia and haemodynamics. Also noteworthy is the use Higher inotropic or vasoactive drug support, as measured
of an initial single dose of epidural morphine used for fast- by VIS on admission to the ICU postoperatively, is often
tracking. It has been described successfully in a study by taken as a sign of compromised ventricular function, which
Peterson et al., wherein 89% of the patients were extubated will not allow for safe early extubation. However, a higher
in the operating room. Peterson et al. used preservative VIS score was not associated with failure to fast-track the
free morphine sulphate at a dose of 40–70 mcg/kg along patients in our study. Another common condition that clini-
with bupivacaine epidurally in a single-shot cohort [9]. We cians take a cautious approach, to tracheal extubation, is in
did not observe any adverse events related to TEA in our patients with Down syndrome [19, 20]. However, we found
study. However, given an accepted incidence of 1:150,000 to that all 14 patients with Down syndrome could be success-
1:220,000 for peridural hematoma, we do not intend to imply fully extubated within 6 h without any adverse events or
that TEA is safe in paediatric cardiac surgery. reintubation.

Factors affecting fast‑tracking

Reintubations
Apart from the anaesthetic management, the surgical tech-
nique, CPB management and the postoperative ICU care are The reintubation rates in a population of young children
important steps in the practice of safe fast-tracking, espe- undergoing cardiac surgery have been reported to be around
cially with complex congenital heart surgery. Our centre 2–5% [21, 22]. The reintubation rate in our study was higher
has been successfully practising extubation in the operating than that in previously reported studies. This could perhaps
room after surgery for CHD since 5 years [17]. The protocol be due to the limited exclusion criteria applied by us, rather
was driven by a poor nurse:patient ratio and a single anaes- than choosing to apply the fast-track protocol only for low-risk
thesiologist doubling as an intensivist. Factors like preopera- cases. Nonetheless, the rates of reintubation in neonates and
tive ventilation, preoperative sepsis, or patients on ECMO smaller infants undergoing cardiac surgery were comparable
before or during surgery had to be excluded from early extu- to other studies [4]. In our series, the reasons for reintubation
bation. Therefore, this subset of patients was excluded from were diverse and did not follow any specific trend (Table 3).
our analyses. Other perceived challenges in fast-tracking Poor cardiac function and PHT were the most common rea-
include younger age, long CPB time, high inotrope use, sur- sons for tracheal reintubation. The appropriate weaning strate-
gery complexity and PHT [1, 2]. gies and extubation criteria have been much debated and still
We analysed the effect of these limiting factors on suc- await a consensus [18]. We attempted to refine the ability to
cessful early extubation (Table 5). We noted that low nadir predict failed extubation on the basis of pre-operative and

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Indian Journal of Thoracic and Cardiovascular Surgery

intra-operative assessment and prevent reintubation. In our Conflict of interest None.

study, 55% of patients were extubated within 6 h and about
80% within 24 h on admission to the ICU and this could be
achieved with our successful fast-track protocol. References

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