Variation in perioperative care across centers for infants undergoing the Norwood procedure

Department of Pediatrics and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. Electronic address: .
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 06/2012; 144(4):915-21. DOI: 10.1016/j.jtcvs.2012.05.021
Source: PubMed


In the Single Ventricle Reconstruction trial, infants undergoing the Norwood procedure were randomly allocated to undergo a right ventricle-to-pulmonary artery shunt or a modified Blalock-Taussig shunt. Apart from shunt type, subjects received the local standard of care. We evaluated variation in perioperative care during the Norwood hospitalization across 14 trial sites.
Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who underwent the Norwood procedure were collected prospectively on standardized case report forms, and variation across the centers was described.
Gestational age, birth weight, and proportion with hypoplastic left heart syndrome were similar across sites. In contrast, all recorded variables related to preoperative care varied across centers, including fetal diagnosis (range, 55%-85%), preoperative intubation (range, 29%-91%), and enteral feeding. Perioperative and operative factors were also variable across sites, including median total support time (range, 74-189 minutes) and other perfusion variables, arch reconstruction technique, intraoperative medication use, and use of modified ultrafiltration (range, 48%-100%). Additional variation across centers was seen in variables related to postoperative care, including proportion with an open sternum (range, 35%-100%), median intensive care unit stay (range, 9-44 days), type of feeding at discharge, and enrollment in a home monitoring program (range, 1%-100%; 5 sites did not have a program). Overall, in-hospital death or transplant occurred in 18% (range across sites, 7%-39%).
Perioperative care during the Norwood hospitalization varies across centers. Further analysis evaluating the underlying causes and relationship of this variation to outcome is needed to inform future studies and quality improvement efforts.

4 Reads
    • "This complex procedure demands technical expertise, thorough understanding of the physiology of the Norwood circulation, intensive care backup, and a multispeciality approach to the perioperative management. Though there have been large series from various centers in the developed nations with good outcomes, this procedure has not become popular in the Indian scenario.[1] The relatively high mortality associated with this surgery, high resource utilization, lack of dedicated intensive care support, and inability of the family to accept the concept of staged palliation in view of the economic burden have all put surgeons on the back foot in performing this complex repair. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The evolution of surgical skills and advances in pediatric cardiac intensive care has resulted in Norwood procedure being increasingly performed in emerging economies. We reviewed the feasibility and logistics of performing stage one Norwood operation in a limited-resource environment based on a retrospective analysis of patients who underwent this procedure in our institution. Retrospective review of medical records of seven neonates who underwent Norwood procedure at our institute from October 2010 to August 2012. The median age at surgery was 9 days (range 5-16 days). All cases were done under deep hypothermic cardiopulmonary bypass and selective antegrade cerebral perfusion. The median cardiopulmonary bypass (CPB) time was 240 min (range 193-439 min) and aortic cross-clamp time was 130 min (range 99-159 min). A modified Blalock-Taussig (BT) shunt was used to provide pulmonary blood flow in all cases. There were two deaths, one in the early postoperative period. The median duration of mechanical ventilation was 117 h (range 71-243 h) and the median intensive care unit (ICU) stay was 12 days (range 5-16 days). Median hospital stay was 30.5 days (range 10-36 days). Blood stream sepsis was reported in four patients. Two patients had preoperative sepsis. One patient required laparotomy for intestinal obstruction. Stage one Norwood is feasible in a limited-resource environment if supported by a dedicated postoperative intensive care and protocolized nursing management. Preoperative optimization and prevention of infections are major challenges in addition to preventing early circulatory collapse.
    No preview · Article · Mar 2013 · Annals of Pediatric Cardiology

  • No preview · Article · Oct 2012 · The Journal of thoracic and cardiovascular surgery
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although overall outcomes for children undergoing heart surgery have improved, there is a significant variation in outcomes across hospitals. This review discusses the variation in cost and outcomes across centres performing congenital heart surgery, potential underlying mechanisms, and efforts to reduce variation and improve outcome.
    No preview · Article · Dec 2012 · Cardiology in the Young
Show more