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Early extubation after surgical repair of tetralogy of Fallot

Article  in  Cardiology in the Young · December 2000

DOI: 10.1017/S1047951100008933 · Source: PubMed

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Lara Shekerdemian Daniel Penny

Texas Children's Hospital Baylor College of Medicine
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 Cardiol Young 2000; 10: 636-637
© Greenwich Medical Media Ltd.
ISSN 1047-9511

Brief Report

Early extubation after surgical repair of tetralogy of Fallot

Lara S. Shekerdemian, Daniel J. Penny, William Novick

International Children's Heart Foundation, University Hospital, Maracaibo, Venezuela

Abstract In recent years, post-operative intensive care of the child with congenital cardiac disease has
placed an emphasis on earlier weaning from mechanical ventilation. We describe our experience of post-
operative fast-tracking of children undergoing cardiac surgery during a charitable mission in Venezuela,
where resources and equipment were severely limited. During our stay, 11 children, with a median age of 2
years, underwent total correction of tetralogy of Fallot. The median duration of ventilation was 2.5 hours,
and all patients were extubated within 12 hours of surgery. Effective analgesia was achieved without the
need for continuous intravenous infusions of opiates. This experience shows that early extubation can safely
be carried out in well-selected patients after surgery to correct congenital cardiac malformations. This allows
faster throughput of patients, and helps provide an efficient and cost-effective service.

Keywords: Intensive care; fast tracking; mechanical ventilation

T
HE APPROACH TO THE POSTOPERATIVE CARE FOR
children after cardiac surgery has undergone
fundamental changes in recent years.
Traditional protocols which emphasized cautious
weaning of support and, in some patients, continu-
ation of anaesthesia into the early postoperative
period, have been replaced by attempts to achieve
early separation from mechanical ventilation and
fast-tracking. 12 This new approach has been driven
by an increasing appreciation of the additional
morbidity which can result from prolonged stay in
intensive care and of the potential adverse haemo-
dynamic effects of mechanical ventilation in some
patients, as well as by economic considerations. This
report describes our experience of fast-tracking of
children following surgery for congenital heart
disease during a charitable mission where resources
and equipment were severely limited.
Setting
The International Children's Heart Foundation,
University Hospital, Maracaibo, Venezuela.
Correspondence to: Dr. Lara Shekerdemian, Cardiac Intensive Care Unit, Great
Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK. Tel:
44-20-7405 9200; Fax: 44-20-7829 8673; E-mail: lara.shekerdemian@gosh-
tr.nthames.nhs.uk
Accepted for publication 25 July 2000
Paediatric Intensive Care Unit with three fully
functional Servo 900C ventilators, a variable
oxygen supply, and 1 or 2 syringe drivers per
patient.
Patients
We studied 11 children, 4 boys and 7 girls, with a
median age of 2 years, ranging from 0.6 to 14
years, all with tetralogy of Fallot. All patients were
cyanosed pre-operatively, with saturations of
oxygen between 55 and 88%. All children
underwent complete surgical correction and were
transferred from the operating room to the
intensive care unit for post-operative management.
Anaesthesia and analgesia
Anaesthesia was induced in all patients with
ketamine, and maintained with fentanyl, isoflurane
(0.5—1.5% in oxygen / nitrous oxide mix), and
pancuronium boluses.
Post-operative analgesia consisted of parac-
etamol, given in a dose of 20mg/kg, immediately
upon return from the operating room, and then
15mg/kg 6 hourly regularly for one or two days. In
children over 1 year, ibuprofen at a dose of
lOmg/kg was given on arrival on the intensive care
unit, and 8-hourly thereafter if necessary.
Vol. 10, No. 6 Shekerdemian et al: Early extubation after surgical repair of tetralogy of Fallot 637
Intravenous analgesia was not routinely adminis-
tered. All patients had 1 or 2 chest drains in place
for at least 24 hours.

Results
The median duration of ventilation was 2.5 hours,
with a range from 0 to 12 hours. Extubation
occurred in the operating room in 3 children, with
the remainder extubated on the intensive care
unit. One child required surgical re-exploration
for bleeding shortly after admission to the
intensive care unit, and was subsequently extu-
bated at 12 hours. Another child required re-intu-
bation at 18 hours for acute pulmonary
haemorrhage. As far as we are aware, there were
no deaths in this group.

Discussion
Early extubation is not only feasible, but can be
safely carried out in the right setting: that is with
experienced medical and nursing staff present, in
the child who is sufficiently awake, and in the
absence of significant post-operative bleeding. We
were impressed that intravenous analgesia, even in
the children with chest drains in place, did not
appear to be necessary in the majority of cases, as
long as the child had received sufficient alternative
analgesia administered pre-emptively (Fig. 1). Many
of the children in this group were old enough to be
able verbally to communicate with their parents or
with the intensive care staff, with the help of inter-
preters. Thus, we did not have to rely only on the
'softer' markers of discomfort, such as haemody-
namic parameters, facial expression, and crying.
Instead, we were able to ask directly whether or not
they felt pain.
In modern intensive care, it is unusual to be so
limited in terms of resources so as to have to 'ration'
use of ventilators, intravenous drugs, and so on.
These 11 patients with tetralogy of Fallot were the
largest diagnostic sub-group of a total of 32
children, with a variety of complex diagnoses, who
underwent cardiac surgery during a visit by the
International Children's Heart Foundation to
Figure 1.
A 4-year-old boy 6 hours after returning to the intensive care unit
following repair of tetralogy of Fallot. This child was extubated 2
hours post-operatively, had just had his first drink, and is seen here
doing his own 'physiotherapy'. He hadreceived paracetamol and non-
steroidal analgesia since returning from surgery.
Maracaibo, Venezuela. With only three fully func-
tional ventilators, 10 operating days, and a large
number of children awaiting surgery, it was imper-
ative to ensure a fast but efficient service on the
intensive care unit in order to allow as many
children as possible the chance of surgery.
References
1. Lake, CL. Fast tracking the paediatric cardiac surgical patient.
Paediatric Anaesthesia 2000; 10: 231-236.
2. Turley K, Tyndall M, Turley K. Radical outcome method. A
new approach to critical pathways in congenital heart disease.
Circulation 1995; 92 (suppl II): 11-245-11-249.