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Congenital Heart Disease GUEST EDITORIAL Congenital heart disease Pediatric Anesthesia is the only anesthesia journal ded- who developed hypoglycemia were infants. (9). Steven icated exclusively to perioperative issues in children and Nicolson take the opposite approach of ‘first do undergoing procedures under anesthesia and sedation. no harm’ (10). If we do not want ‘tight glycemic con- It is a privilege to be the guest editor of this special trol’ because of concern about hypoglycemic brain issue dedicated to the care of children with heart dis- injury, when should we start treating blood sugars? ease. The target audience is anesthetists who care for There are no clear answers based on neurological out- children with heart disease both during cardiac and comes in children. non-cardiac procedures. The latter takes on increasing Williams and Cohen (11) discuss the care of low importance as children with heart disease undergoing birth weight (LBW) infants and their outcomes. Pre- non-cardiac procedures appear to be at a higher risk maturity and LBW are independent risk factors for for cardiac arrest under anesthesia than those without adverse outcomes after cardiac surgery. Do the anes- heart disease (1). We hope the articles in this special thetics we use add to this insult? If prolonged exposure issue will provide guidelines for management and to volatile anesthetics is bad for the developing neona- spark discussions leading to the production of new tal brain, would avoiding them make for improved guidelines. outcomes? Wise-Faberowski and Loepke (12) review Over a decade ago Austin et al. (2) demonstrated the current research in search of a clear answer and the benefits of neurological monitoring during heart conclude that there isn’t one. So we muddle along with surgery in reducing adverse neurological outcomes in a mix of anesthetics not sure whether we are helping children. It is not yet standard of care and the current improve outcomes or not. level of evidence supporting its routine use is level 2 For the purist, Wong and Morton (13) present ideas (non-randomized controlled trials). However Kasman on total intravenous anesthetics and target controlled and Brady (3) wonder if the burden of proof we infusions (TCI). Since ‘early extubation’ and early dis- impose on the cerebral oximeter to improve neurologi- charge from the intensive care unit and length of stay cal outcomes is reasonable. The article on transesopha- are closely tracked by insurance payors, TCI has consid- geal echocardiography (TEE) by Kamra et al. (4), erable appeal. Once the patient is in intensive care, man- coupled with the video clips available online, provides aging their pain and sedation becomes important (14). a comprehensive overview of TEE in children. Moni- Children with heart failure are a growing segment of toring and treating coagulation disorders after heart patients for whom pediatric anesthesiologists must surgery (5) and the risks of transfusion are reviewed care. These children are often subjected to multiple and provide guidelines for management provided (6). diagnostic tests and interventions for which anesthesia With improved survival after heart surgery, the is required. Rosenthal and Hammer (15) discuss the number of children with cardiac rhythm management current etiologies and pathogenesis of heart failure and devices (CRMD) has substantially increased. Navarat- offer ideas for safe perioperative care. Once vasodila- nam and Dubin (7) present a practical approach on tor and other medical therapy fails, these children are how to care for patients with these devices in the peri- then placed on mechanical assist devices (16). Finally, operative period. The information on CRMD, along some of these children undergo heart transplantation with White’s (8) practical approach to children with and their perioperative management and outcomes are heart disease for non-cardiac surgery, provides a addressed (17). framework for managing these patients. Traditionally, mortality has been the outcome mea- Of the many controversies in the perioperative man- sure of success or failure of a surgical program. Thia- agement of children during heart surgery, glucose con- garajan and Laussen (18) offer a thoughtful expose´on trol or lack thereof, is high on the list. A recent why low mortality should no longer be the yardstick placebo controlled, large, prospective study of patients with which to measure success. Other quality indica- in a pediatric intensive care unit reported that ‘tight tors are urgently needed if we are to improve the peri- glycemic control’ resulted in shorter intensive care unit operative care of children with heart disease after length of stay, reduced lactate levels, decreased C-reac- cardiac surgery. tive protein and reduced incidence of infections. How- Doherty and Holtby (19) address the issue of the ever the incidence of hypoglycemia (blood glucose unavailability of pediatric subspecialists for the care of <40 mg)1 dl) was higher in the intensive insulin treat- children with heart disease in developing countries. ment group (25%) and the majority (80%) of patients Finally, as adults with congenital heart disease Pediatric Anesthesia 21 (2011) 471–472 ª 2011 Blackwell Publishing Ltd 471 Editorial (ACHD) now outnumber the children with heart dis- ease, where should the adults be cared for (20)? Will Chandra Ramamoorthy Department of Anesthesiology, care givers be from the adult world or will they be Stanford University Medical Center, pediatric subspecialists? Seal (21) reviews current data Stanford, CA, and discusses their care model in Alberta, Canada, USA Guest Editor where pediatric cardiac anesthesiologists also manage ACHD. Are we pediatric anesthesiologists or cardiac doi:10.1111/j.1460-9592.2011.03592.x anesthesiologists specializing in congenital heart dis- ease? Time to ponder. References 1 Ramamoorthy C, Haberkern CM, erative care. Pediatr Anesth 2011; 21: 512– 15 Rosenthal DN, Hammer GB. Cardiomyopa- Bhananker S et al. Anesthesia-related car- 521. thy and heart failure in children: anesthetic diac arrest in children with heart disease: 8 White MC. Approach to managing children implications. Pediatr Anesth 2011; 21: 577– data from the Pediatric Perioperative Car- with heart disease for noncardiac surgery. 584. diac Arrest (POCA) registry. Anesth Analg Pediatr Anesth 2011; 21: 522–529. 16 Mossad EB, Motta P, Rossano J et al. Peri- 2010; 110: 1376–1382. 9 Vlasselaers D, Milants I, Desmets L. et al. operative management of pediatric patients 2 Austin EH, Edmonds HL, Auden SM et al. Intensive insulin therapy for patients in on mechanical cardiac support. Pediatr Benefit of neurolophysiologic monitoring pediatric intensive care: a prospective ran- Anesth 2011; 21: 585–593. for pediatric cardiac surgery. J Thorac Car- domized controlled study. Lancet 2009; 373: 17 Schure AY, Kussman BD. Pediatric heart diovasc Surg 1997; 114: 707–715. 717. 547–556. transplantation: demographics, outcomes, 3 Kasman N, Brady K. Cerebral oximetry for 10 Steven J, Nicholson S. Perioperative man- and anesthetic implications. Pediatr Anesth pediatric anesthesia: why do intelligent clini- agement of blood glucose during open heart 2011; 21: 594–603. cians disagree? Pediatr Anesth 2011; 21: surgery in infants and children. Pediatr 18 Thiagarajan RR, Laussen PC. Mortality as 473–478. Anesth 2011; 21: 530–537. an outcome measure following cardiac sur- 4 Kamra K, Russell I, Miller-Hance WC. 11 Williams GD, Cohen RS. Perioperative gery for congenital heart disease in the Role of transesophageal echocardiography management of low birth weight infants for current era. Pediatr Anesth 2011; 21: 604– in the management of pediatric patients open-heart surgery. Pediatr Anesth 2011; 21: 608. with congenital heart disease. Pediatr Anesth 538–553. 19 Doherty C, Holtby H. Pediatric cardiac 2011; 21: 479–493. 12 Wise-Faberowski L, Loepke A. Anesthesia anesthesia in the developing world. Pediatr 5 Arnold P. Treatment and monitoring of during surgical repair for congenital heart Anesth 2011; 21: 609–614. coagulation abnormalities in children under- disease and the developing brain: neurotoxic 20 Marelli A J., Therrien J, Mackie A S. et al. going heart surgery. Pediatr Anesth 2011; or neuroprotective? Pediatr Anesth 2011; 21: Planning the specialized care of adult con- 21: 494–503. 554–559. genital heart disease patients: from numbers 6 Guzzetta NA. Benefits and risks of red 13 Wong GLS, Morton NS. Total intravenous to guidelines; an epidemiologic approach. blood cell transfusion in pediatric patients anesthesia (TIVA) in pediatric cardiac anes- Am Heart J 2009; 157: 1–8. undergoing cardiac surgery Pediatr Anesth thesia. Pediatr Anesth 2011; 21: 560–566. 21 Seal R. Adult congenital heart disease. Pedi- 2011; 21: 504–511. 14 Wolf AR, Jackman L. Analgesia and seda- atr Anesth 2011; 21: 615–622. 7 Navaratnam M, Dubin A. Pediatric pace- tion after pediatric cardiac surgery. Pediatr makers and ICDs: how to optimize periop- Anesth 2011; 21: 567–576. 472 Pediatric Anesthesia 21 (2011) 471–472 ª 2011 Blackwell Publishing Ltd Pediatric Anesthesia ISSN 1155-5645 REVIEW ARTICLE Adult congenital heart disease Robert Seal Department of Anesthesia and Pain Medicine, University of Alberta and Stollery Children’s Hospital, Edmonton AB Canada Keywords Summary congenital heart disease; general anesthesia; cardiac surgery For a decade now, it has been recognized that optimal management of adult congenital heart disease (ACHD) requires a skilled multidisciplinary Correspondence team. The size and complexity of the population of adults with congenital Robert Seal, heart disease (CHD) are increasing. This article reviews the general consid- Department of Anesthesia and Pain erations for giving an anesthetic to an adult with CHD for cardiac or non- Medicine, University of Alberta and Stollery cardiac surgery and provides further elaboration for a variety of complex Children’s Hospital, 1C1.04 WMC, 8440 112 Street, Edmonton AB T6G 2B7, Canada patient types. Lastly, the advantages of an organized multidisciplinary Email: [email protected] approach to patients with ACHD are discussed. Accepted 17 March 2011 doi:10.1111/j.1460-9592.2011.03591.x living adults (9%) have complex CHD (9).
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