A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery.

Background: Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM to reduce blood product utilization during and after neonatal and infant cardiac surgery.

Anesthesia for thoracic surgery in infants and children.

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment.

Bloodless Arterial Switch Operation in a 2.7-kg Jehovah's Witness Patient.

Bloodless pediatric cardiac surgery requiring the use of cardiopulmonary bypass (CPB) remains a challenge for the entire operating room (OR) team. The amount of circulating blood volume to pump prime volume mismatch of small patients results in hemodilution that frequently results in transfusion of allogeneic blood products. Patients of families of the Jehovah's Witness (JW) faith reject the use of these products because of religious beliefs.

Quality Improvement Project in Congenital Cardiothoracic Surgery Patients: Reducing Surgical Site Infections.

Background: Healthcare-associated infections are a major focus for quality improvement in hospitals today. Surgical site infections (SSIs), a postoperative complication in cardiac surgery, are associated with increased morbidity, mortality, hospital length of stay, and financial burden.

Methods: A recent increase in cardiothoracic surgery SSIs (CT-SSIs) at our institution instigated a multidisciplinary team to explore infection prevention, bundle element compliance, and to identify interventions to reduce the CT-SSI rate.

There's an App for That; Improving Communication during Pediatric Cardiothoracic Surgery.

Introduction: Waiting while a loved one is in surgery can be a very stressful time. Current processes for updating families vary from institution to institution. Providing timely and relevant updates, while important to the family, may strain a surgical team's operational system.

The Impact of Three Different Wash Solutions on Autotransfusion Products.

Many blood conservation techniques and strategies have been implemented to aid in decreasing the use of allogenic blood utilization during pediatric cardiothoracic surgery. Use of techniques, such as acute normovolemic hemodilution, retrograde autologous prime, venous autologous prime, and autotransfuion, may lead to a decrease in the need for allogenic blood products. Autotransfusion has become a standard of care for all cardiothoracic surgical procedures requiring cardiopulmonary bypass (CPB).

Pediatric Pulmonary Artery Rehabilitation: A Review of Our Experience and a Novel Approach Using Bronchial Blockers.

Recent advances in the field of pediatric interventional cardiology have resulted in therapies for patients in need of augmented pulmonary artery (PA) flow. Catheter-based PA rehabilitation can be performed safely but not without the potential risk of pulmonary hemorrhage. When severe, this bleeding has the ability to contaminate the bronchi and trachea, and possibly occlude the endotracheal tube.

Revisiting acute normovolemic hemodilution and blood transfusion during pediatric cardiac surgery: a prospective observational study.

Background: The majority of allogeneic transfusions occur in the perioperative setting, especially during cardiac surgery. In addition to the economic implications, there is emerging evidence that blood transfusion may increase both morbidity and mortality. Acute normovolemic hemodilution (ANH) may limit the need for blood products.

The Correlation of Two Cerebral Saturation Monitors With Jugular Bulb Oxygen Saturation in Children Undergoing Cardiopulmonary Bypass for Congenital Heart Surgery.

Background: Near-infrared spectroscopy (NIRS) is a noninvasive monitoring technique that measures regional cerebral oxygen saturation (rSO).

Objectives: The primary aim was to compare the output of 2 NIRS-based cerebral oximetry devices, FORESIGHT (CAS Medical Systems Inc, Branford, Connecticut) and INVOS (Covidien, Boulder, Colorado), to venous oxygen saturations from the jugular venous bulb at cannulation and decannulation of the superior vena cava (SVC). Secondary objectives included evaluating correlations of cerebral saturation, as measured by the NIRS devices, with mean arterial blood pressure (MAP), measured by an invasive arterial line, and end-tidal CO (ETCO).

A single-center strategy to minimize blood transfusion in neonates and children undergoing cardiac surgery.

Background: The transfusion of blood products in the setting of uncontrolled bleeding is unquestionably lifesaving. However, in many instances, the decision to transfuse is based on physician gestalt rather than medical evidence. When indications for transfusion are unclear, the benefits of blood products must be balanced against their significant risks and associated costs.

Neurodevelopmental outcome after cardiac surgery utilizing cardiopulmonary bypass in children.

Introduction: Modulating the stress response and perioperative factors can have a paramount impact on the neurodevelopmental outcome of infants who undergo cardiac surgery utilizing cardiopulmonary bypass.

Materials And Methods: In this single center prospective follow-up study, we evaluated the impact of three different anesthetic techniques on the neurodevelopmental outcomes of 19 children who previously underwent congenital cardiac surgery within their 1(st) year of life. Cases were done from May 2011 to December 2013.

Quality improvement methodologies increase autologous blood product administration.

Whole blood from the heart-lung (bypass) machine may be processed through a cell salvaging device (i.e., cell saver [CS]) and subsequently administered to the patient during cardiac surgery.

The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study.

Objectives: Our goal was to evaluate the role of three anesthetic techniques in altering the stress response in children undergoing surgery for repair of congenital heart diseases utilizing cardiopulmonary bypass in the setting of fast tracking or early tracheal extubation. Furthermore, we wanted to evaluate the correlation between blunting the stress response and the perioperative clinical outcomes.

Design: Prospective, randomized, double-blinded study.

Decreasing the need for transfusion: infant cardiac surgery using hemodilution and recombinant factor VIIa.

Many strategies, including intraoperative acute normovolemic hemodilution (ANH) and pharmacologic agents, exist to minimize the use of allogeneic blood products in pediatric congenital heart surgery. Recombinant activated factor VIIa (rFVIIa) is a hemostatic agent approved for the treatment of bleeding episodes and prevention of bleeding in surgical interventions in patients with hemophilia A or B with inhibitors, acquired hemophilia, or congenital factor VII deficiency. Off-label use in nonhemophilic patients for uncontrolled hemorrhage is increasing although still under investigation.

Pain management after comprehensive stage 2 repair for hypoplastic left heart syndrome.

Achieving optimal pain control for children after complex cardiac surgery can be challenging. Recently, the hybrid approach to palliation of hypoplastic left heart syndrome (HLHS) was introduced as an alternative to the classic Norwood procedure. The second stage of the hybrid approach is a complex procedure known as comprehensive stage 2 (CS2).

Pain management after surgery for single-ventricle palliation using the hybrid approach.

The hybrid pathway for the management of patients with hypoplastic left heart syndrome was pioneered at our institution and is the preferred approach compared with the traditional Norwood pathway. Patients undergoing this surgery are generally <6 months of age, and pain management in this age group after surgery for complex congenital heart disease (CHD) may be particularly challenging. We retrospectively reviewed our pain-management strategy after stage 1 hybrid procedure (HS1) and evaluated its efficacy, especially in the setting of early tracheal extubation.

Changes in hemodynamic parameters and cerebral saturation during supraventricular tachycardia.

Induced supraventricular tachycardia (SVT) during electrophysiology studies (EPS) can be associated with hemodynamic changes. Traditionally, invasive arterial blood pressure has been used for continuous monitoring of these changes. This prospective study evaluated the efficacy of near-infrared spectroscopy (NIRS) monitoring during SVT.

Perioperative care of an infant with an anomalous left innominate artery arising from the main pulmonary artery.

A 1.4-kilogram, male infant was born at 27 weeks gestation at an outside hospital. After birth, the patient's trachea was intubated and surfactant administered.

Changes in near-infrared spectroscopy and the bispectral index during tilt-table examination.

The head-upright tilt-table test is an important tool for the diagnosis of vasodepressor or neurocardiogenic syncope. The use of noninvasive near-infrared spectroscopy (NIRS) monitoring and bispectral index (BIS) monitoring during these cases can add another tool to the real-time monitoring and aid in their diagnosis. The authors report their experience using NIRS and BIS monitoring during tilt-table testing to investigate syncope in a 14-year-old adolescent.

Anesthetic management of the hybrid stage 1 procedure for hypoplastic left heart syndrome (HLHS).

Introduction: Despite advances in the surgical and perioperative management of patients with hypoplastic left heart syndrome (HLHS), outcomes for this high-risk group of patients remains suboptimal. The hybrid approach [bilateral pulmonary artery (PA) banding, ductal stenting, balloon atrial septostomy], is an emerging alternative therapy for the management of HLHS, which defers the risks of a major surgical repair until the infants are older. This article will describe our experience providing the anesthetic management of patients undergoing the hybrid procedure.