Postoperative complications in pediatric cardiac surgery patients done in a tertiary hospital

Ahmed H Gamal; El-Minshawy K Ahmed; Ismail E Ahmed; Sadek A Omar

doi:10.4103/JCMRP.JCMRP_130_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 5 | Issue : 2 | Page : 121-125

Postoperative complications in pediatric cardiac surgery patients done in a tertiary hospital

Ahmed H Gamal¹, El-Minshawy K Ahmed², Ismail E Ahmed², Sadek A Omar²
¹ Deparment of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
² Deparment of Cardiothoracic Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt

Date of Submission	08-Sep-2019
Date of Decision	01-Oct-2019
Date of Acceptance	10-Oct-2019
Date of Web Publication	16-May-2020

Correspondence Address:
Sadek A Omar
Building No. 9, 3^rd Floor, Ferial Taqsium Malek Next to El Hayat Hospital
Egypt

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/JCMRP.JCMRP_130_19

Abstract

Introduction
Postoperative complications can involve several organs and have a major effect on in-hospital stay length and quality of life of the children after discharge from the hospital. Although the complications are strictly related to the surgical procedure, postoperative pulmonary complications represent an important and probably underestimated cause of morbidity and mortality in postoperative pediatric heart surgery.
Aim
The aim of this study was to evaluate the relation between complication and the overall outcome.
Patients and methods
This retrospective descriptive study included 100 children (ages from 0 to 18 years old, excluding preterm babies) who underwent open heart surgery in Cardiothoracic Surgery Department of Assiut University in a 1-year period. The preoperative and intraoperative parameters included technique of operation, cardiopulmonary bypass time, and aortic cross-clamp time. The postoperative parameters included occurrence of postoperative complications, such as arrhythmias, heart failure, pulmonary congestion with chest infection, wound infection, and bleeding, and hospital stay of the patients.
Results
The occurrence of complications after congenital heart surgeries using cardiopulmonary bypass has significant relation with the cardiopulmonary bypass time; therefore, the longer the cardiopulmonary bypass time, the more the probability of cardiac and extracardiac complications. This study shows the same result as studies in adult surgery, demonstrating that complications after heart surgery significantly are associated with increased hospital stay time.
Conclusion
Surgery is the optimal and the final treatment for congenital heart diseases; nearly a quarter of the patients who undergo congenital heart surgery experience postoperative complications, complex congenital heart diseases with different degrees of heart failure, or respiratory failure, and carry more risk for complications. So close monitoring and timely intervention and treatment are very critical to avoid occurrence of multiple complications as reported in our study.

Keywords: cardiopulmonary bypass, congenital heart surgery, tetralogy of Fallot, pediatric, postoperative complications

How to cite this article:
Gamal AH, Ahmed EMK, Ahmed IE, Omar SA. Postoperative complications in pediatric cardiac surgery patients done in a tertiary hospital. J Curr Med Res Pract 2020;5:121-5

How to cite this URL:
Gamal AH, Ahmed EMK, Ahmed IE, Omar SA. Postoperative complications in pediatric cardiac surgery patients done in a tertiary hospital. J Curr Med Res Pract [serial online] 2020 [cited 2022 Aug 14];5:121-5. Available from: http://www.jcmrp.eg.net/text.asp?2020/5/2/121/284388

Introduction

Congenital cardiopathy is the commonest congenital anomaly, estimated recently at 6–10 for each 1000 live births. A large number of these infants need surgery to correct or palliate their heart defect; many of them need surgery in the newborn period^[1].

The development of heart-lung machine has been essential for the treatment of most congenital cardiopathies. There is a difference between using heart-lung machine in adults and in children, as a result of the issues of aortopulmonary shunts, the undeveloped cardiovascular system, and the circumstantial occurrence of deep hypothermic circulatory arrest.

The more prolonged the cardiopulmonary bypass time is, the more the hazardous effects on these factors, as cardiopulmonary bypass plays an overload role on the systemic circulation, which is almost compromised by prior heart failure.

Heart-lung machine, specific surgical technique, anesthesia, and different medications may result in production of multisystemic complications^[2]. Postoperative care stresses mainly on expecting potentially hazardous effects and a timely intervention to revive cardiopulmonary homeostasis and to avoid end organ damage^[3].

Postoperative period in children requires a much closer observation compared with adults because of the onset of continual changes regarding age, growth, maturation, development, preoperative state, and surgical technique. Newborns particularly because of the immaturity of primarily cardiovascular, respiratory, neurological, and renal systems may result in large numbers of complications that lead to increase in the morbidity and mortality.

Children who experience complex congenital heart diseases with different degrees of heart failure, respiratory failure, or shock are at a risk of multiple concomitant complications. Mortality rate in these patients is expected to be higher, as these patients require more complex surgeries. Nowadays, the mortality rate as reported by many centers is approximately 6% compared with 3% only in adult heart surgery.

Since the past years, congenital heart surgery has shown marked improvement and advancement. However, still postoperative complications either general or lesion-specific complications are to be expected early after surgery. The main role is to avoid low cardiac output and to prevent major organ affection. Acute low cardiac output, pulmonary hypertension, and diastolic dysfunction are examples of the most critical general complications, whereas valve dysfunction, residual shunts, or residual obstruction of ventricular outflow tracts, are likely to be anticipated after several congenital heart diseases and surgical techniques.

We aim to discuss the complications that occur after congenital heart surgeries and to evaluate the relation between these complications and the outcome measures.

Patients and Methods

Study population

This is a retrospective descriptive study performed on 100 pediatric patients who underwent cardiac surgery in Assiut University Cardiothoracic Surgery Department who met the listed inclusion and exclusion criteria over a 1-year period. Ethics committee approval number 17100832.

Inclusion criteria

All pediatric patients indicated for cardiac surgery with/without usage of cardiopulmonary bypass (age ranging from 0 to 18 years old, excluding preterm babies) were included, except those mentioned in exclusion criteria.

Exclusion criteria

The following were the exclusion criteria:

Heart and lung transplantations.
Patients on mechanical ventilation before intervention.
Patients with preoperative medical disorders other than cardiac affection.
Redo patients.

The preoperative and intraoperative data included type of operation, cardiopulmonary bypass time, and aortic cross-clamp time.

The postoperative data included occurrence of postoperative complications such as arrhythmias, heart failure, pulmonary congestion with chest infection, wound infection, and bleeding, as well as hospital stay of the patients.

Patient characteristics recorded were as follows:

Age (years).
Sex.
Weight (kg).
Laboratory data.

Preoperative and postoperative variables recorded were as follows:

Echocardiography.
ECG.
Pulmonary artery systolic pressure.
Laboratory data.
Heart rate (bpm).
Temperature.

Results

Of the 100 patients, VSD-closure is the commonest procedure (34%) followed by TOF-correction (19%), as shown in [Table 1].

Table 1: Surgical procedure

Click here to view

Of these patients, only 20% had preoperative pulmonary hypertension, as shown in Fig. 1.

Average cardiopulmonary total bypass time (TBT) and average ischemic time (IT) were 102.73 ± 23.00 and 71.82 ± 17.64 min, respectively, as shown in [Table 2].

Table 2: Cardiopulmonary bypass

Click here to view

Of the five studied complications, chest infection is the commonest (10%) followed by heart failure (8%), and wound infection and pulmonary hypertension (7% each), as shown in Fig. 2.

Mortality accounted for 7% in our study, as shown in [Table 3]. Moreover, the study showed that there is a significant relation between cardiopulmonary TBT and IT and outcome (hospital stay, complications, and mortality rate), as shown in [Table 4] and [Table 5], respectively. The study also showed a significant relation between complexity of procedure and outcome (complications and mortality rate increased in patients with tetralogy of Fallot), as shown in [Table 6].

Table 3: Outcome

Click here to view

Table 4: Relation between total bypass time and outcome

Click here to view

Table 5: Relation between ischemic time and outcome

Click here to view

Table 6: Outcome according to tetralogy of Fallot

Click here to view

Discussion

Surgery is the optimal and the real final treatment for pediatric congenital heart diseases, and as any other invasive procedure, it is associated with several complications. So after open heart surgery, close monitoring and timely intervention and treatment are very critical to avoid occurrence of multiple complications as reported in our study.

Although there are no comprehensive studies of complication diagnoses during pediatric open heart surgery admissions, certain types of complications have been examined in different studies. Such as, studies examining nosocomial infections have reported that approximately 22% of patients underwent pediatric heart surgery acquired at least one nosocomial infection^[4],[5],[6]. During stay in the postoperative intensive care unit, 18% of the patients experienced an arrhythmia owing to medical or surgical causes^[7]. Other complications that occurred after pediatric heart surgery have been reported as follows: hepatic complication (9%)^[8], cardiac tamponade (7%)^[9], and diaphragmatic paralysis (5.4%)^[10]. Many cases of isolated complications are also reported^{[11],[12],[13],[14]}.

This study shows the same result as other studies in adult cardiac surgery which show that complications after heart surgery are significantly associated with increased hospital stay time^[15],[16]. Moreover, they show the significant relation between postoperative complications and mortality rate as an agreement with the results from different studies^[17],[18].

In addition, there are many limitations in our study. It shows postoperative complications among 100 patients, with age range from 0 to 18 years. Overall, 35% of the patients were aged less than 3 years old, 31% aged from 3 to 6 years old and 31% aged more than 6 years old. It also shows that 51% of the patients were males and 49% were females. Our study found that VSD was the commonest case diagnosis operated in our center in 34%, followed by TOF in 19% then ASD in 16%, PDA in 10%, subaortic membrane in 9%, mitral regurge in 8%, pulmonary stenosis in 7%, CoA in 2%, and others (including partial and complete A-V canal and single ventricle) in 5%. Of all of these cases, 80% have no pulmonary hypertension and 20% have pulmonary hypertension of different grades (mild 11%, moderate 5%, and severe 4%).

In our study, we only studied five postoperative complications, which are arrhythmia, bleeding, sepsis including chest and wound infection, pulmonary hypertension, and heart failure. We observed that chest infection is the commonest complication, accounting for 10% of all patients, followed by heart failure (8%), wound infection (7%), pulmonary hypertension (7%), postoperative bleeding (4%), and arrhythmia (3%).

Mortality accounted for 7% in our study. Moreover, the study showed that there is a significant relation between cardiopulmonary TBT and IT and outcome (hospital stay, complications, and mortality rate), in which the longer the cardiopulmonary bypass time, the more probability of cardiac and extracardiac complications. The study also showed a significant relation between complexity of procedure and outcome (complications and mortality rate increased in patients with tetralogy of Fallot).

Comparison of the present study with a previous study conducted in Assiut University Hospital by Ghoneim et al.^[19] shows that postoperative mortality rate was 5.6%. It also shows that postoperative complications account for 54.5% compared with 23% in our study, as they encountered all types of postoperative complications not only the five complications discussed by us. It also shows that postoperative serious arrhythmia is the commonest complication (28%) followed by postoperative fever and chest infections (12%). Both studies agreed that we must increase our experience in the management of congenital heart patients and in the postoperative ICU intervention strategies.

Conclusion

Nearly a quarter of the patients who underwent congenital heart surgery experienced postoperative complications, and it is reflected on the pediatric cardiac ICU and hospital stay and increasing mortality rate.

Cardiac surgery is at high risk for postoperative complications, involving the heart itself or other organs, most importantly kidneys, lungs, and brain. Efforts should be made to identify preoperatively patients at high risk for the development of complications, and more studies are warranted to clarify the role of the determinants of these complications, including type of anesthesia, mechanical ventilation, and postoperative management of vasoactive drugs.

Acknowledgements

Deep thanks to the whole department for contributing toward the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Krishnamurthy G, Ratner V, Bacha E. Neonatal cardiac care a perspective seminars in thoracic and cardiovascular surgery. Pediat Cardiac Surg Ann 2013; 16:21–31.
2.	Beke DM, Braudis NJ, Lincoln P. Management of the pediatric postoperative cardiac surgery patient. Crit Care Nurs Clin N Am 2005; 17:405–416.
3.	Miletic KG, Spiering TJ, Delius RE, Walters HL, Mastropietro CW. Use of a novel vasoactive-ventilation-renal score to predict outcomes after pediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2014; 20:289–295.
4.	Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ. The impact of nosocomial infections on patient outcomes following cardiac surgery. Chest 1997; 112:666–675.
5.	Levy I, Ovadia B, Erez E, Rinat S, Ashkenazi S, Birk E, et al. Nosocomial infections after cardiac surgery in infants and children incidence and risk factors. J Hosp Infect 2003; 53:111–116.
6.	Mrowczynski W, Wojtalik M, Zawadzka D, Sharma G, Henschke J, Bartkowski R, et al. Infection risk factors in pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2002; 10:329–333.
7.	Hoffman TM, Wernovsky G, Wieand TS, Cohen MI, Jennings AC, Vetter VL, et al. The incidence of arrhythmias in a pediatric cardiac intensive care unit. Pediatr Cardiol 2002; 23:598–604.
8.	Vazquez P, Lopez-Herce J, Carrillo A, Sancho L, Bustinza A, Diaz A. Hepatic dysfunction after cardiac surgery in children. Pediatr Crit Care Med 2001; 2:44–50.
9.	Johnston LJ, McKinley DF. Cardiac tamponade after removal of atrial intracardiac monitoring catheters in a pediatric patient: case report. Heart Lung 2000; 29:256–261.
10.	Joho-Arreola AL, Bauersfeld U, Stauffer UG, Baenziger O, Bernet V. Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children. Eur J Cardiothorac Surg 2005; 27:53–57.
11.	Mogayzel PJ Jr, Colombani PM, Crawford TO, Yang SC. Bilateral diaphragm paralysis following lung transplantation and cardiac surgery in a 17-year-old. J Heart Lung Transplant 2002; 21:710–712.
12.	Parry RL, Gordon S, Sherman NJ. Pulmonary artery band migration producing endobronchial obstruction. J Pediatr Surg 1997; 32:48–49.
13.	Rosen DA, Hawkinberry DW 2^nd, Rosen KR, Gustafson RA, Hogg JP, Broadman LM. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 2004; 98:966–969.
14.	Sharoni E, Erez E, Birk E, Katz J, Dagan O. Superior vena cava syndrome following neonatal cardiac surgery. Pediatr Crit Care Med 2001; 2:40–43.
15.	Lazar HL, Fitzgerald C, Gross S, Heeren T, Aldea GS, Shemin RJ. Determinants of length of stay after coronary artery bypass graft surgery. Circulation 1995; 92 (9 Suppl):II20–II24.
16.	Welsby IJ, Bennett-Guerrero E, Atwell D, White WD, Newman MF, Smith PK, et al. The association of complication type with mortality and prolonged stay after cardiac surgery with cardiopulmonary bypass. Anesth Analg 2002; 94:1072–1078.
17.	Benavidez OJ, Gauvreau K, Del Nido P, Bacha E, Jenkins KJ. Complications and risk factors for mortality during congenital heart surgery admissions. Ann Thorac Surg 2007; 84:147–155.
18.	Pasquali SK, He X, Jacobs JP, Jacobs ML, O'Brien SM, Gaynor JM. Evaluation of failure to rescue as a quality metric in pediatric heart surgery: an analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2012; 94:573–580.
19.	Ghoneim AMF, Elshafy SKA, El-Hafez AFA, Allah EA, El-minshawy A. Risk stratified outcome of congenital heart surgery in Assiut University Pediatric cardiothoracic surgery unit. J Egypt Soc Cardiothorac Surg 2013; 21:79–90.