Perioperative events in children with pulmonary hypertension undergoing non-cardiac procedures

Abstract

Prior limited research indicates that children with pulmonary hypertension (PH) have higher rates of adverse perioperative outcomes when undergoing non-cardiac procedures and cardiac catheterizations. We examined a single-center retrospective cohort of children with active or pharmacologically controlled PH who underwent cardiac catheterization or non-cardiac surgery during 2006-2014. Preoperative characteristics and perioperative courses were examined to determine relationships between the severity or etiology of PH, type of procedure, and occurrence of major and minor events. We identified 77 patients who underwent 148 procedures at a median age of six months. The most common PH etiologies were bronchopulmonary dysplasia (46.7%), congenital heart disease (29.9%), and congenital diaphragmatic hernia (14.3%). Cardiac catheterizations (39.2%), and abdominal (29.1%) and central venous access (8.9%) were the most common procedures. Major events included failed planned extubation (5.6%), postoperative cardiac arrest (4.7%), induction or intraoperative cardiac arrest (2%), and postoperative death (1.4%). Major events were more frequent in patients with severe baseline PH ( P = 0.006) and the incidence was associated with procedure type ( P = 0.05). Preoperative inhaled nitric oxide and prostacyclin analog therapies were associated with decreased incidence of minor events (odds ratio [OR] = 0.32, P = 0.046 and OR = 0.24, P = 0.008, respectively), but no change in the incidence of major events. PH etiology was not associated with events ( P = 0.24). Children with PH have increased risk of perioperative complications; cardiac arrest and death occur more frequently in patients with severe PH and those undergoing thoracic procedures. Risk may be modified by using preoperative pulmonary vasodilator therapy and lends itself to further prospective studies.

Keywords: bronchopulmonary dysplasia; outcomes; pediatric; pulmonary vascular disease.

Fig. 1.

PH severity and thoracic procedures were associated with major events. (a) Severity of PH at the time of procedure; most had mild PH. (b) Incidence of major and minor events by PH severity classification. Patients with severe PH had a higher incidence of major events (P = 0.006). The incidence of minor events did not differ significantly between groups. (c) Numbers of each procedure type performed. (d) The incidence of major and minor events by procedure. Approximately one-third of central venous access, thoracic, and airway procedures were marked by a major event. The incidence of major events was disproportionately high for thoracic procedures (P = 0.05). No differences in the incidence of minor events were noted between groups.