Original Research
The Characterization of Postoperative Mechanical Respiratory Requirement in Neonates and Infants Undergoing Cardiac Surgery on Cardiopulmonary Bypass in a Single Tertiary Institution

https://doi.org/10.1053/j.jvca.2021.04.023Get rights and content

Objectives

Although neonates and infants undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at high risk of developing perioperative morbidity and mortality, including lung injury, the intraoperative profile of lung injury in this cohort is not well-described. Given that the postoperative course of patients in the pediatric cardiac surgical arena has become increasingly expedited, the objective of this study was to characterize the profiles of postoperative mechanical ventilatory support in neonates and infants undergoing cardiac surgery on CPB and to examine the characteristics of lung mechanics and lung injury in this patient population who are potentially amendable to early postoperative recovery in a single tertiary pediatric institution.

Design

A retrospective data analysis of neonates and infants who underwent cardiac surgery on cardiopulmonary bypass.

Setting

A single-center, university teaching hospital.

Participants

The study included 328 neonates and infants who underwent cardiac surgery on cardiopulmonary bypass.

Interventions

A subset of 128 patients were studied: 58 patients undergoing ventricular septal defect (VSD) repair, 36 patients undergoing complete atrioventricular canal (CAVC) repair, and 34 patients undergoing bidirectional Glenn (BDG) shunt surgery.

Measurements and Main Results

Of the entire cohort, 3.7% experienced in-hospital mortality. Among all surgical procedures, VSD repair (17.7%) was the most common, followed by CAVC repair (11.0%) and BDG shunt surgery (10.4%). Of patients who underwent VSD repair, CAVC repair, and BDG shunt surgery, 65.5%, 41.7%, and 67.6% were off mechanical ventilatory support within 24 hours postoperatively, respectively. In all three of the surgical repairs, lung compliance decreased after CPB compared to pre-CPB phase. Sixty point three percent of patients with VSD repair and 77.8% of patients with CAVC repair showed a PaO2/FIO2 (P/F) ratio of <300 after CPB. Post- CPB P/F ratios of 120 for VSD patients and 100 for CAVC patients were considered as optimal cutoff values to highly predict prolonged (>24 hours) postoperative mechanical ventilatory support. A higher volume of transfused platelets also was associated with postoperative ventilatory support ≥24 hours in patients undergoing VSD repair, CAVC repair, and BDG shunt surgery.

Conclusions

There was a high incidence of lung injury after CPB in neonates and infants, even in surgeries amendable for early recovery. Given that CPB-related factors (CPB duration, crossclamp time) and volume of transfused platelet were significantly associated with prolonged postoperative ventilatory support, the underlying cause of cardiac surgery-related lung injury can be multi-factorial.

Section snippets

Study Cohort

This retrospective cohort study was approved by the Institutional Review Board at Boston Children's Hospital. All neonates and infants who underwent cardiac surgery from January 2019 to December 2019 were identified. Among them, only patients who underwent surgery on CPB were included for analysis. Demographics, surgical type, surgical duration, CPB time, crossclamp time, blood product volumes, intraoperative respiratory data, postoperative mechanical respiratory support time, and postoperative

Characteristics of Infants and Neonates Undergoing Cardiac Surgery on Cardiopulmonary Bypass

Four hundred forty-one neonates and infants underwent cardiac surgery during the time period. Among them, 328 cases were performed on CPB. Their characteristics are shown in Table 1. Postoperative death was noted in 3.7% of patients, which was in line with the Kids’ Inpatient Database study.8 Figure 1 describes the type of surgery performed, and the types of surgeries performed in fewer than three patients were categorized as ‘other.’ The average duration of postoperative mechanical ventilatory

Discussion

Here the authors describe postoperative mechanical ventilatory support for neonates and infants who underwent CHD surgery on CPB. Surgical repair for VSD and CAVC, two overcirculation lesions, were the two most common procedures in this cohort. The authors found that 60% and 80% of neonates and infants after VSD and CAVC repair, respectively, demonstrated a P/F ratio <300, but more than 65% of VSD patients and 40% of CAVC patients did not require postoperative mechanical ventilatory support

Conflict of Interest

None.

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    Financial support: CHMC Anesthesia Foundation (K.Yuki).

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