Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-23T00:17:28.275Z Has data issue: false hasContentIssue false
  • English
  • Français

Early postoperative extubation of unstable patients following total cavopulmonary connection: impact on circulation and outcome

Published online by Cambridge University Press:  18 October 2016

Stanimir Georgiev ,
Gunter Balling ,
Bettina Ruf ,
Kilian Ackermann ,
Jelena P. von Ohain ,
Christian Schreiber  and
Peter Ewert
Stanimir Georgiev*
Affiliation:
Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, Munich, Germany
Gunter Balling
Affiliation:
Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, Munich, Germany
Bettina Ruf
Affiliation:
Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, Munich, Germany
Kilian Ackermann
Affiliation:
Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, Munich, Germany
Jelena P. von Ohain
Affiliation:
Department for Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Germany
Christian Schreiber
Affiliation:
Department for Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Germany
Peter Ewert
Affiliation:
Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich, Munich, Germany
*
Correspondence to: S. Georgiev, Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Lazarettstrasse 36, 80636, Munich, Germany. Tel: +49 89 1218 3306; Fax: +49 89 1218 3333; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives

We aimed to investigate whether early postoperative extubation following the Fontan operation is universally feasible and can be used as a management tool in unstable patients.

Methods

All patients undergoing the Fontan operation in our centre between 2004 and 2013 (n=253) were analysed. Until 2008, patients were extubated according to standard criteria and comprised group 1. Group 2 included all patients presenting after 2009, when early extubation was always aimed regardless of the haemodynamic status. Patients who exceeded the 75th percentiles for volume requirements and inotrope scores for the respective group were defined as unstable. Comparisons of outcomes between groups and subgroups and analysis of the changes in haemodynamic and treatment parameters with extubation in unstable patients after 2009 were performed.

Results

Compared with group 1, patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.50), and needed less volume (p=0.01). In group 2, the unstable patients were not ventilated for longer durations (p=0.19), but had higher re-intubation rates (p=0.03) than the stable patients. Compared with the unstable patients from group 1, the unstable patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.66), and needed less volume (p=0.006). There was a significant acute and sustained increase in mean arterial pressure with extubation and a parallel reduction in volume requirements and inotrope scores in the unstable patients from group 2.

Conclusions

Timely extubation is universally applicable following the Fontan operation. Early postoperative extubation can be valuable for improving Fontan haemodynamics.

Keywords

Fontan operationintensive careearly extubation
Type
Original Articles
Information
Cardiology in the Young , Volume 27 , Issue 5 , July 2017 , pp. 860 - 869
Check for updates
Copyright
© Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Fontan, F, Baudet, E. Surgical repair in triupsid atresia. Thorax 1971; 26: 240–248.CrossRefGoogle ScholarPubMed
2. Dabal, RD, Kirklin, JK, Kukreja, M, et al. The modern Fontan operation shows no increase in mortality out to 20 years: a new paradigm. J Thorac Cardiovasc Surg 2014; 148: 2517–2524.CrossRefGoogle Scholar
3. Ovroutski, S, Sohn, C, Baribkin, P, et al. Analysis of the risk factors for early failure after extracardiac Fontan operation. Ann Thorac Surg 2013; 95: 1409–1416.CrossRefGoogle ScholarPubMed
4. Hosein, RBM, Clarke, AJB, McGuirk, AP, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments?’ Eur J Cardiothorac Surg 2007; 31: 344–353.CrossRefGoogle ScholarPubMed
5. Gewillig, M, Brown, SC, Eyskens, B, et al. The Fontan circulation: who controls cardiac output? Interact Cardiovasc Thorac Surg 2010; 10: 428–433.CrossRefGoogle ScholarPubMed
6. Penny, DJ, Redington, AN. Doppler echocardiographic evaluation of pulmonary blood flow after the Fontan operation: the role of the lungs. Br Heart J 1991; 66: 372–374.CrossRefGoogle ScholarPubMed
7. Hsia, TY, Khambadkone, S, Deanfield, JE, Taylor, JFN, Migliavacca, F, de Leval, MR. Subdiaphragmatic venous hemodynamics in the Fontan circulation. J Thorac Cardiovasc Surg 2001; 121: 436–447.CrossRefGoogle ScholarPubMed
8. Fogel, MA, Weinberg, PM, Hoydu, A. The nature of flow in the systemic venous pathway measured by magnetic resonance blood tagging in patients having the Fontan operation. J Thorac Cardiovasc Surg 1997; 114: 1032–1041.CrossRefGoogle ScholarPubMed
9. Schuller, JL, Sebel, PS, Bovill, JG, Marcelletti, C. Early extubation after Fontan operation: a clinical report. Br J Anaesth 1980; 52: 999–1004.CrossRefGoogle ScholarPubMed
10. Lofland, G. The enhancement of hemodymanic performance in Fontan circulation using pain free spontaneous ventilation. Eur J Cardiothorac Surg 2001; 20: 114–119.CrossRefGoogle Scholar
11. Mutsuga, M, Quinonez, LG, Mackie, AS. Fast-track extubation after modified Fontan procedure. J Thorac Cardiovasc Surg 2012; 144: 547–552.CrossRefGoogle ScholarPubMed
12. Morales, DLS, Carberry, KE, Heinle, J, McKenzie, ED, Fraser, CD, Diaz, LK. Extubation in the operating room after Fontan’s procedure: effect on practice and outcomes. Ann Thorac Surg 2008; 86: 576–582.CrossRefGoogle ScholarPubMed
13. Schreiber, C, Hörer, J, Vogt, M, Cleuziou, J, Prodan, Z, Lange, R. Nonfenestrated extracardial total cavopulmonary connection in 132 consecutive patients. Ann Thorac Surg 2007; 84: 894–899.CrossRefGoogle Scholar
14. Shekerdemian, L. Perioperative manipulation of the circulation in children with congenital heart disease. Heart 2009; 95: 1286–1296.CrossRefGoogle ScholarPubMed
15. Wernovsky, G, Wypij, D, Jonas, RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation, 92: 2226–2235.CrossRefGoogle Scholar
16. Mitternacht, AJC, Thanjan, M, Srivastava, S, et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg 2008; 136: 88–93.CrossRefGoogle Scholar
17. Salvin, JW, Scheurer, MA, Laussen, PC, et al. Factors associated with prolonged recovery after the Fontan operation. Circulation 2008; 118 (Suppl 1): 171–176.CrossRefGoogle ScholarPubMed
18. Costello, JM, Dunbar-Masterson, C, Allan, CK, et al. Impact of empiric nesiritide or milrinone infusion on early postoperative recovery after Fontan surgery: a randomized, double-blind, placebo controlled trial. Circ Heart Fail 2014: 596–604.CrossRefGoogle ScholarPubMed