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

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. 

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.

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).

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

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

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. 

Yes, under careful monitoring.

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.

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. 

Clonidine seems less favourable than Dexmed (5 to 10 fold increase in elimination half-life; more highly selective for the α-2 receptor compared with clonidine (α-2:α1 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.

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). 

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. 

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. 

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. 

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. 

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.

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.