Early Extubation and Fast-Track Postoperative Care in Paediatric Congenital Cardiac Surgery

FREE Online webinar organized by the EACTA Educational Committee and the Paediatric & Congenital Subcommittee

Click here to access the on-demand (available for EACTAIC members)
The Early Extubation and Fast-Track Postoperative Care in Paediatric Congenital Cardiac Surgery, Rome, Italy, 29/03/2021-29/03/2021 has been accredited by the European Accreditation Council for Continuing Medical Education (EACCME®) with 2 European CME credits (ECMEC®s). Each medical specialist should claim only those hours of credit that he/she actually spent in the educational activity.

Take Home message:

Early extubation and fast-track postoperative care should be part of the programme in every institution where congenital cardiac surgery is performed. To do that of course a sustained enhanced recovery programme needs to be implemented by multidisciplinary team members who are experts in congenital heart disease and who are ready to make the next change.

What’s in it for me?

After joining this webinar, you will better understand:

  • The feasibility and safety of fast-track paediatric cardiac anaesthesia;
  • The principles of developing a successful fast-track programme for paediatric cardiac surgery;
  • The impact of heart-lung interaction in paediatric congenital cardiac surgery;
  • The benefits and considerations for using dexmedetomidine for fast-track paediatric cardiac anaesthesia.

Target Audience:

Paediatric cardiac surgeons, cardiovascular anaesthetists, perfusionists, paediatric intensivists, general anaesthetists, anaesthesia certified nurses, nurses, interns, and medical students.

Acknowledgement: photo in the banner is by Steffen Rex, MD, PhD
Have a look at the results of the poll submitted to the webinars’ participants. Do you agree with the results?



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Event Details
10
Days
50
Hours
10
Min
00
Sec
Start Date
March 29, 2021 5:00 pm
End Date
March 29, 2021 7:30 pm
Status
Expired
Scientific Moderator:

Mona Momeni
Belgium

Programme:
Time Topic Speaker
17:00–17:10 Introduction to the webinar Mona Momeni, Belgium
17:10–17:40 What is the evidence for fast-track anaesthesia? Joost van der Maaten, The Netherlands
17:40–18:10 How to implement a successful fast-track programme? Susan C. Nicolson, Philadelphia, USA
18:10–18:40 Heart-lung interaction in congenital cardiac anaesthesia Walid Habre, Switzerland
18:40–19:10 Dexmedetomidine: Usefulness for fast-track anaesthesia? Steffen Rex, Belgium
19:10–19:30 Q&A from the audience -

The webinar is supported by an unrestricted educational grant by Livanova.

LivaNova PLC is a global medical technology and innovation company built on nearly five decades of experience and a relentless commitment to provide hope for patients and their families through innovative medical technologies, delivering life-changing improvements for both the Head and Heart. Headquartered in London, LivaNova employs approximately 4,000 employees and has a presence in more than 100 countries for the benefit of patients, healthcare professionals and healthcare systems worldwide. LivaNova operates as two businesses: Cardiovascular and Neuromodulation, with operating headquarters in Mirandola (Italy) and Houston (U.S.), respectively. For more information, please visit www.livanova.com

I have no experience with levomepromazine. If teh child is still agitated despite the use of dex, other reasons for agitation should be ruled out and treated: hypoxia, pain, fear, thirst, hunger, etc. Depending on the prevailing symptoms, low dose propofol or benzodiazepines are also an option. We hardly see severe emergence agitations after dex - perhaps because we never use ketamine for the maintenance of anesthesia.
Speakers: Steffen Rex

We start dexmedetomidine at a dose of 0.5-1 µg/kg/h after induction of anesthesia and continue it throughout the procedure and on the ICU. Yes, dex can perfectly be used for cardiac MRI. Speakers: Steffen Rex

Clonidine has a much lower selectivity for alpha-2 receptors which means that hemodynamic side effects are more pronounced. Moreover, dex has an elimination half life of approximately 1.9-2.5h (clonidine: 12-24h). As such, clonidine is less favourable than dex (however, randomized controlled comparisons are lacking).
Speakers: Steffen Rex

No. And high quality evidence for iv lidocaine is still lacking - even in adults and even in abdominal surgery.
Speakers: Steffen Rex

I am not aware of an addiction problem. Tachyphylaxis has been described after infusion of 24h necessitating dose adjustments.
Speakers: Steffen Rex

Dex can be perfectly used for procedural sedation. However, I doubt whether dex is sufficient for bronchoscopy in children - we are performing these procedures under general anetshesia.
Speakers: Steffen Rex

Yes, under careful monitoring.
Speakers: Steffen Rex

Dex can be perfectly used for procedural sedation. Wea re using it routinely for MRI (bolus application of 2µg/kg, repeated by a bolus of 1µg/kg after 20min). For CT, we use 2.7µg/kg intranasally.
Speakers: Steffen Rex

Thank you very much for your interest in EACTAIC Fellowship Programmes. Currently, the EACTAIC Task Force from the Paediatric Subscpeialty Committee and Education Committee works to develop a curriculum and implement an EACTAIC Fellowship Programme. That might be ready by the end of 2021. However, preliminary joining that programme might require previous training in general paediatric anaesthesia and adult cardiothoracic anaesthesia. Stay tuned, and EACTAIC will publish this information after being developed.
Speakers: Mohamed R. El Tahan

Clonidine seems less favourable than Dexmed (5 to 10 fold increase in elimination half-life; more highly selective for the ?-2 receptor compared with clonidine (?-2:?1 agonist activity of 1,600:1 vs 200:1). Data are limited on the consequences of cessation of the clonidine infusion with regard to rebound hypertension and withdrawal symptoms.
Speakers: Joost van der Maaten

In the ERAS program of Boston Children's they used local anesthetic on incision supplemented with a multimodal drug-based pain regimen. Literature on the use of bilateral erector spinae block in pediatric cardiac surgery is limited (see a recent paper by Kaushal et al. DOI: 10.1053/j.jvca.2019.08.009).
Speakers: Joost van der Maaten

The maximum vasoactive-inotrope score (VIS) within 24 h after ICU admission has been assessed as a good predictor of unfavourable outcomes after paediatric cardiac surgery. In one of the studies I referred to (Harris et al. DOI: 10.1016/j.jtcvs.2014.06.093), inotrope use (not specified) was a predictor of failed early extubation. However, the suitability for early extubation was based on subjective evaluation (no protocol) and the study had no control group. To date there is no clear cut-off value of the VIS. In most cases a low to moderate dose of vasoactive-inotropic support would not withhold an early extubation trajectory.
Speakers: Joost van der Maaten

There is quite often a lack of information regarding the practical aspects of recommended procedures. I suppose the same precautions should be taken care of as utilized in the PICU. Accidental catheter/drain removal was not mentioned as a potential problem after early extubation in these children.
Speakers: Joost van der Maaten

The preoperative administration of anti-failure therapy alone is not a contraindication for the patient to be considered a candidate for immediate (on the table) or early (withing 6 hours of completion of the surgery). The patient's condition at the end of the procedure determines suitabilty - i.e - absence of hemodynamically significant residual lesions, bleeding, arrythmias, escalating inotropic support, open chest etc.
Speakers: Susan C. Nicolson

Prehabilitation has been shown to decrease complications and enhance recovery. Clinicians are just starting to define prehabilitation prior to pediatric cardiac surgery. Ideas include: optimizing nutritional status, minimizing heart failure symptoms, structured exercise program and psychological preparation in older children and adolescents.
Speakers: Susan C. Nicolson

Consideration should be given to extubation on the table or on arrival to the intensive care unit prior to initiation of mechanical ventilation. In addition to the individual patient's status, the state of the OR (subsequent case) and ICU (acuity, personnel avaiable to manage a newly extubated, fresh post-op patient) need to be considered and discussed with other members of the team.
Speakers: Susan C. Nicolson

Since we don’t have a specific way to measure SVR, we’re left with using a mix of indicators. Clinically, we look at the overall hemodynamics, such as blood pressure, CVP, heart rate, SaO2, urine output and near-infrared spectroscopy (NIRS), as well as acid-base status, lactic acid levels, mixed-venous oxygen saturation (SmvO2) and the ventricular and atrioventricular valve function on echocardiography to determine if our support is adequate or if we need to adjust support of either contractility and/or vasomotor tone.
Speakers: Susan C. Nicolson