Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience

• Published in: Indian journal of thoracic and cardiovascular surgery Vol. 38; no. 5; pp. 469 - 480
• Main Authors: Kumar, Alok, Ramamurthy, H. R., Tiwari, Nikhil, Joshi, Saajan, Kumar, Gaurav, Kumar, Vivek, Sharma, Vipul
• Format: Journal Article
• Language: English
• Published: Singapore Springer Nature Singapore 01.09.2022
• Subjects: Cardiac Surgery; Medicine; Medicine & Public Health; Original; Original Article; Surgery; Thoracic Surgery; Vascular Surgery; Fast-tracking; Congenital heart surgery; Thoracic epidural analgesia; Congenital heart disease
• ISSN: 0970-9134; 0973-7723
• DOI: 10.1007/s12055-022-01373-8

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 suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery.