Peri-operative Anesthetic Innovations
During Pediatric Cardiac Surgery
Thierry V. Scohy
ISBN 978 94 6169 101 9
Cover design: Sarah, Sofi a and Luca Scohy
Copyright 2011 T.V. Scohy
All rights reserved. No part of this thesis may be reproduced, distributed, stored in a
retrieval system or transmitted in any form or by any means, without permission of the
author, or when appropriate, of the publishers of the publications.
Peri-operative Anesthetic Innovations
During Pediatric Cardiac Surgery
Peri-operatieve anesthetische vernieuwingen
ter verkrijging van de graad van doctor aan de
Erasmus Universiteit Rotterdam
op gezag van de
rector magnifi cus
Prof.dr. H.G. Schmidt
en volgens besluit van het College voor Promoties.
De openbare verdediging zal plaatsvinden op
vrijdag 28 oktober 2011 om 11:30 uur
Thierry Vincent Scohy
geboren te Lier, België
Prof.dr. A.J.J.C. Bogers
Prof.dr. J. Klein
Prof.dr.ir. N. de Jong
Prof.dr. P.J. de Feyter
Prof.dr. P. Wouters
Dr. D.A.M.P.J. Gommers
Dr. J. Hofl and
Het verschijnen van dit proefschrift werd mede mogelijk gemaakt door de steun van de
TABLE OF CONTENTS
A new transesophageal probe for newborns.
Scohy TV, Matte G, van Neer PL, van der Steen AF, McGhie J, Bogers A,
de Jong N.
Ultrasound Med Biol. 2009;35:1686-9.
Intraoperative evaluation of micromultiplane transesophageal
echocardiographic probe in surgery for congenital heart disease.
Scohy TV, Gommers D, Jan ten Harkel AD, Deryck Y, McGhie J, Bogers AJ.
Eur J Echocardiogr. 2007;8: 241-6.
Image quality using a micromultiplane transesophageal
echocardiographic probe in older children during cardiac surgery.
Scohy TV, Gommers D, Schepp MN, McGhie J, de Jong N, Bogers AJ.
Eur J Anaesthesiol. 2009;26:445-7.
Intraoperative transesophageal echocardiography is benefi cial for
hemodynamic stabilization during left ventricular assist device
implantation in children.
Scohy TV, Gommers D, Maat AP, Dejong PL, Bogers AJ, Hofl and J.
Paediatr Anaesth. 2009;19:390-5.
Rapid method for intraoperative assessment of aortic coarctation using
Scohy TV, du Plessis F, McGhie J, de Jong PL, Bogers AJ.
Eur J Echocardiogr. 2009;10:922-5.
Measurement of end-expiratory lung volume in intubated children
without interruption of mechanical ventilation.
Bikker IG, Scohy TV, Ad J J C Bogers, Bakker J, Gommers D.
Intensive Care Med. 2009;35:1749-53.
Alveolar recruitment strategy and PEEP improve oxygenation, dynamic
compliance of respiratory system and end-expiratory lung volume in
pediatric patients undergoing cardiac surgery for congenital heart
Scohy TV, Bikker IG, Hofl and J, de Jong PL, Bogers AJ, Gommers D.
Paediatr Anaesth. 2009;19:1207-12.
Intraoperative Glycemic Control without Insulin Infusion during Pediatric
Cardiac Surgery for Congenital Heart Disease.
Scohy TV, Golab HD, Egal M, Takkenberg JJM, Bogers AJJC.
Paediatr Anaesth. 2011 Apr 4. (Epub ahead of print)
List of publications
Ge neral introduction
General Introduction 9
CONGENITAL HEART DISEASE: A SHORT NOTE OF HISTORY
Congenital heart disease (CHD) refers to a series of birth defects that aff ect the heart and
thoracic vessels, aff ecting 6 to 8 out of 1,000 babies being born. In 40% of these children
no treatment is indicated because of minimal eff ect on hemodynamics and outcome.
In 60% treatment will be required; about half of them will require urgent surgery after
birth, while the other half will probably require surgery or medication at some point
during childhood. Due to advances in heart surgery, 85% of children with congenital
heart disease will survive into adulthood (1).
Although CHD has been recognized for centuries, therapeutic options were not avail-
able until the 20th century (2). Until the late 1930s little advances were made in cardiac
surgery due to a lack of refi nement in anesthesia and problems related to now routine
perioperative support techniques, such as blood transfusion and mechanical ventilation
(3). After the fi rst successful ligation of a patent ductus arteriosus in 1938 (4), a lot of
new operations found their origin. In 1949 perioperative mortality, approached 14.5%
(5). In the 1950s extracorporeal circulation made its entry. The introduction of new an-
esthetic drugs and the use of prostaglandins to maintain ductal patency and pulmonary
blood fl ow was one of the most important advances of the 1970s (6). In the late 1970s
cardioplegia solutions were introduced. During the 1980s sufentanil and midazolam
off ered alternatives to potent volatile anesthetics, although hospital mortality was
still 6% (7). From the 1990s miniaturizing components of the cardiopulmonary bypass
circuit reduced priming volumes, producing less coagulation factor dilution and further
improvement in patient outcome.
During the past two decades, mortality after surgery for congenital cardiac disease has
decreased dramatically and is now reported to be 4% in the European Association for
Cardio-thoracic Surgery and the Society of Thoracic Surgeons Congenital Heart Surgery
Database (8), the focus of clinical research and eff orts to improve quality has now shifted
to that of the minimization of morbidity (9).
ASPECTS OF QUALITY
Although quality management is a major strategic issue in health care organizations,
there is little agreement on the precise defi nition and content of quality and quality
management (10). Most often concepts and tools regard organizational quality and
originate from industry. For instance, the Netherlands implemented into the govern-
mental medical safety design policy, a report from a Royal Dutch Shell director, “In this
organisation you work safely, otherwise you don’t work here at all”, plays a key-role (11).
10 General Introduction
The Orde van Medische Specialisten (organisation for medical specialists in the Neth-
erlands) reports that professional medical practice quality is seen as interplay between
product-quality, process-quality, and structure-quality (12). Product-quality has aspects
of Good Clinical Practice like: effi ciency, expertise, making adequate indications for
medical care, capability, safety and carefulness. Process-quality has aspects of attitude
like: respectful treatment, willingness to give adequate information, trustful relation-
ship, cooperation and accountability. Structure-quality has aspects of organisational
management like: continuity of care, availability of care, functionalism and integrated
From the point of view of the medical professional, however, quality directly relates
to the delivery of medical care. One should approach each patient asking not only “How
can I provide the best care in this case?” but also “How can I improve the care I provide?”.
This opens the way to innovative care.
Although, effi cacy and cost-eff ectiveness are important aspects, innovative care may
at some point introduce less effi ciency and may initially seem to increase costs. When
however the medical professional results improve, a new reality for the organization is
According to Deming a quality improvement cycle consists of planning, doing, check-
ing and acting (13). This fi ts elegantly for improving patient care i.e. for application of
This thesis concerns aspects of innovative care and quality improvement in the opera-
tive treatment of pediatric patients with congenital heart disease.
LATEST IMPROVEMENTS OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
AND ITS APPLICATION IN CLINICAL PRACTICE OF CHILDREN WITH CHD
Until 1990, intraoperative evaluation of infants and children undergoing congenital
heart surgery was not feasible with TEE because probe sizes were too large (14). The de-
velopment of miniaturized single- and bi-plane probes demonstrated that TEE could be
performed safely in the pediatric population (15). A multiplane TEE probe which obtains
images in several planes is an obvious advantage, certainly considering the complexity
of the intracardiac defects. Until 2007, the use of mini-multiplane TEE probe (10.7 – 8.0
mm diameter tip with a 7.4 mm diameter shaft) was still limited to children above the
weight of 5 kg (16).
In Chapter 1 we describe the physical characteristics and the acoustic properties of
the Oldelft microMulti TEE probe (8.2 – 7 mm diameter tip with a 5.2 mm diameter shaft),
a new technology that was developed at the Thoraxcentre to study neonates and small
General Introduction 11
In Chapter 2 we evaluated the clinical and diagnostic ability of this new technology
in 42 neonates and infants (as small as 2.5 kg) undergoing cardiac surgery to provide
data on safety and feasibility. Chapter 3 describes the limitations, loss of image quality
in larger children (>25 kg) of the Oldelft micromultiplane TEE probe.
In Chapter 4 we highlight an aspect of clinical necessity of intraoperative TEE. Mechani-
cal circulatory support with a left ventricle assist device (LVAD) is used in an increasing
number of children for treatment of advanced heart failure as bridge to transplant. In
adult patient care, intra-operative TEE plays a key-role in evaluating LVAD cannula posi-
tioning, haemodynamic stabilisation and the eff ect of device settings on right and left
heart function. No data were available and no studies defi ned the role of intra-operative
TEE for haemodynamic stabilisation during LVAD implantation in children. Therefore,
we studied the utility of intra-operative TEE in pediatric patients undergoing centrifugal
Aortic coarctation should be considered as a complex cardiovascular syndrome
(17,18,19). There is controversy about the accurate assessment of the haemodynamic
signifi cance of blood fl ow obstruction caused by re-stenosis after aortic coarctation
repair, for as the arm-leg blood pressure diff erence may not necessarily represent the
haemodynamic signifi cance of re-stenosis (20). Although an exact assessment of the
aortic anatomy is required for an optimal surgical repair, no feasible intra-operative
visualisation of a possible residual stenosis of the aorta exists. Till today, a brachial-ankle
blood pressure diff erence of > 20 mmHg (18) or > 30 mmHg (21) is the only intra-opera-
tive indication for residual stenosis. Therefore, we decided to assess the feasibility of 3D
echocardiography by assessing intra-operative morphological details of aortic coarcta-
tion and its repair in children. By this way three-dimensional echocardiography made its
very fi rst clinical entrance in pediatric cardiac anesthesia and surgery (Chapter 5).
Chapters 4 and 5 show how innovation improves medical professional result and
becomes a new reality.
END-EXPIRATORY LUNG VOLUME AND MECHANICAL VENTILATION
With regard to reducing morbidity after congenital heart surgery, pulmonary complica-
tions and central airway problems are a frequent cause for delayed recovery following
cardiac surgery in infants and small children (22).
Ventilation can profoundly alter cardiovascular function via complex processes (9),
due to the location of lungs and heart in the thoracic cavity. These processes refl ect the
interaction between many factors like: Ventricular function, Circulating blood volume,
Distribution of the fl ow of blood, Autonomic tone, Volume of air in the lungs, or pulmo-
nary volume, and Intrathoracic pressure (23).
12 General Introduction
Changes in pulmonary volume alter autonomic tone and pulmonary vascular resis-
tance, and at high pulmonary volumes compress the heart. Hyperinfl ation increases
pulmonary vascular resistance and the pressure in the pulmonary arteries, impeding
right ventricular ejection. Decreases in pulmonary volume induce alveolar collapse and
hypoxia, stimulating an increased pulmonary vasomotor tone by the process of hypoxic
pulmonary vasoconstriction. Maneuvers of alveolar recruitment, positive end-expiratory
pressure, and continuous positive airway pressure may reverse hypoxic pulmonary va-
soconstriction and reduce the pressure in the pulmonary arteries (9).
General anaesthesia is known to promote lung volume reduction, which prompts
atelectasis, lung compliance and arterial oxygenation (24). In children, decreased
lung volume is of special importance because of the lower elastic retraction forces
and a lower relaxation volume, which makes them more prone to airway collapse (25).
Monitoring end-expiratory lung volume (EELV) is a valuable tool to optimise respiratory
settings that could be of importance in mechanically ventilated pediatric patients (26).
We evaluated the feasibility and precision of an ICU ventilator with an inbuilt nitrogen
wash-out/wash-in technique in mechanically ventilated pediatric patients. In Chapter 6
the results of EELV measurements in pediatric post-operative cardiac surgery patients
are given. Optimising alveolar recruitment by alveolar recruitment strategy (ARS) and
maintaining lung volume with adequate positive end-expiratory pressure (PEEP) would
allow preventing ventilator-induced lung injury (VILI). In Chapter 7 we describe the ef-
fect of ARS and PEEP on variables like oxygenation and compliance of the respiratory
system in paediatric patients undergoing cardiac surgery for CHD. Here again we see
how innovation improves medical professional result and can become a new reality in
common clinical practice.
INTRAOPERATIVE GLYCEMIC CONTROL DURING PEDIATRIC CARDIAC
Several studies report that the occurrence of hyperglycemia in the postoperative period
is associated with increased morbidity and mortality rates in children after cardiac sur-
gery for congenital heart disease (27-30). However, an association with intraoperative
management or complexity of congenital heart disease has not yet been assessed.
Lately there is concern that glycemic control in the peri-operative period, aiming
at avoiding hyperglycemia while maintaining a strict euglycemic target, could place
patients at risk for hypoglycemia and hereby enhance the risk for adverse outcome (27,
In the light of this controversy we report on our pediatric cardiac anesthesiological
management and the blood glucose levels during open cardiac surgery for congenital
General Introduction 13
heart disease in Chapter 8. Amongst other items, this chapter refl ects the aspects of
quality management in a research setting: Plan (clinical research planning), Do (collect
data), Check (data analysis) and Act (implementation).
AIM OF THE THESIS
The aim of this thesis is to study actual aspects of perioperative care in pediatric cardiac
surgery by applying innovative techniques and concepts in order to improve the quality
Quality of care in pediatric cardiac anesthesia is clearly an evolving work in progress.
Good surgical team behaviour (34), process improvements, structural improvements,
and increases in expertise have diminished overall mortality rates.
14 General Introduction
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