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Eur J Cardiothorac Surg 2001;19:127-134
© 2001 Elsevier Science NL

Perioperative determinants and outcome of cardiopulmonary arrest in children after heart surgery

P. Suominena, R. Paloa, H. Sairanenb, K.T. Olkkolac, J. Räsänend

a Helsinki University Central Hospital, Department of Anaesthesia and Intensive Care, Hospital for Children and Adolescent, University of Helsinki, Stenbäckinkatu 9, Finland 00029 HUS, Finland
b Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Stenbäckinkatu 9, Finland 00029 HUS, Finland
c Department of Anaesthesia and Intensive Care, University of Helsinki, Finland 00029 HUS, Finland
d Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA

Received 15 May 2000; received in revised form 20 November 2000; accepted 6 December 2000.

Corresponding author. Tel.: +358-9-471-73724; fax: +358-9-471-76711
e-mail: pertti.suominen{at}huch.fi


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Objectives: To identify perioperative factors associated with postoperative cardiopulmonary arrest (CA) in the pediatric intensive care unit (PICU) in children undergoing cardiovascular surgery, and to report the outcome of cardiopulmonary resuscitation (CPR) in these patients. Methods: We reviewed the medical records of all patients under 16 years of age who had undergone cardiovascular surgery and sustained CA in PICU in an urban, tertiary care children's hospital over a 5-year period. We used two control groups of patients who recovered without CA. (1) Sixty-five patients, who were operated under deep hypothermic circulatory arrest (DHCA) during the study period. (2) All patients who underwent repair of congenital heart lesions without DHCA in 1994 (n=278). Results: Eighty-two children experienced CA during postoperative care in PICU, mainly from cardiovascular causes. Thirty-four (41%) were declared dead without attempted resuscitation, CPR was initiated in 48 (59%). The primary survival rate was 56% and 1 year survival rate was 19%. The incidence of CA was 3.6% for closed heart operations, 4.9% for intra-cardiac surgery without DHCA, and 27% for operations involving DHCA. Thirty-three per cent of patients with CA arrested during the first 24 postoperative h. Preoperative mechanical ventilation (P=0.03), prostaglandin E1 (P=0.001) and inotropic support (P=0.04) were given significantly more frequently to patients who postoperatively required CPR, compared to control groups. Patients in whom CPR was attempted were younger than the 1994 controls (0.4 vs. 1.2 years; P<0.04), had longer mean aortic-cross-clamp times (76 vs. 51 min; P<0.0001) and cardiopulmonary bypass times (124 vs. 85 min; P<0.0002), and required more inotropic support upon leaving the operating room (P<0.0001). Patients who received CPR had significantly longer DHCA times (53 vs. 32 min; P<0.0002) and required more inotropic support than patients in the DHCA control group (P<0.002). Conclusions: CA after pediatric cardiac surgery is associated with repair of complex congenital heart anomalies in patients who require preoperative mechanical ventilation and vasoactive agents, prolonged aortic cross-clamp, circulatory arrest; and heavy postoperative inotropic support.

Key Words: Cardiac arrest • Paediatric resuscitation • Aortic-cross-clamp • Cardiopulmonary bypass • Deep hypothermic circulatory arrest • Inotropes


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Cardiac surgery remains a difficult area for outcome prediction in the intensive care unit (ICU) [1]. The majority of general ICU scoring systems do not adequately address the specific characteristics of cardiac surgery patients. Preoperative cardiopulmonary failure and acidosis have been identified as markers of poor outcome in children after heart surgery [2]. Complex cardiac operations requiring prolonged aortic-cross-clamping (ACC) are associated with high morbidity and mortality from direct damage to the myocardium [1,3]. Temporary myocardial depression after cardiopulmonary bypass (CPB) and ACC can occur even after an otherwise satisfactory operation. After correction of complex congenital heart defects (CHD) in infants and children, myocardial performance is usually normal during the 2 initial postoperative h; the nadir of cardiac function occurs after 4–8 h [4]. The CPB-induced late neutrophil activation, and hypoxantine and free radical production up to 10 h after CPB have been implicated as a potential mechanism of postoperative cardiopulmonary dysfunction [4,5]. Myocardial depression is usually self-limited lasting 12–24 h [6]. In eldery patients, CPB time over 140 min, ACC time over 120 min and need for postoperative inotropic support at the time of ICU admission are associated with increased postoperative mortality [3].

Paediatric patients recovering from cardiovascular surgery have been included in various in-hospital resuscitation studies [7–10]. However, there are only two studies available concerning the relative contributions of the type of congenital heart disease or the perioperative course to the risk for postoperative cardiopulmonary arrest in children undergoing cardiovascular surgery [11,12]. The purpose of the present study was to examine the role of factors such as preoperative cardiopulmonary support, ACC, CPB, deep hypothermic circulatory arrest (DHCA) time; and postoperative inotropic agents on the incidence and outcome of cardiac arrest (CA) in the PICU after repair of congenital heart defects.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
The Hospital for Children and Adolescents (HCA) at Helsinki University Central Hospital is a 165-bed tertiary care teaching hospital nationally responsible for the care of paediatric patients requiring open-heart surgery in Finland. Only isolated, primarily closed-heart operations are performed in the other university hospitals. The HCA has an eight-bed paediatric intensive care unit (PICU) in which postoperative cardiovascular surgery patients constitute an average 80% of all admissions.

The study was approved by the Ethics Committee of the HCA. We were able to identify all children, who had been resuscitated during recovery from cardiac operations in the PICU between January 1, 1990 and December 31, 1994, by reviewing the medical records of all PICU admissions during that time. Procedures performed in the cardiac catheterization laboratory and patients who only underwent pacemaker placement, were not included. We used two control groups. (1) All patients, who were operated under DHCA during the study period and recovered without CA. (2) All patients who underwent repair of congenital heart lesions without DHCA in 1994 and recovered without CA (Table 1).


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  		Table 1. Characteristics of study and control group patientsa

 
Information regarding the perioperative factors was abstracted from the cardiovascular patient database and from the anaesthesia and CPB records. Data concerning the arrest and subsequent course were collected from the cardiac arrest form and from the progress notes. We recorded the type of the primary CHD; need for preoperative ventilatory support, prostaglandin E1, and inotrope infusions on the arrival operating room (OR); ACC, CPB and DHCA times for the open-heart surgery patients, the dose of inotropes upon leaving the operating room, the time of arrest, initial cardiac rhythm, and outcome. Data from patients in whom a short circulatory arrest of 10 min or less was used to facilitate a difficult phase in the procedure, where either included to the 1994 control group or excluded if the operation was not performed in 1994.

The management of anesthesia and CPB varied little during the study period. Patients older than 6 months were premedicated with flunitrazepam (100 µg/kg, maximum dose 2 mg), those younger than 6 months received no premedication. Anesthesia was induced with fentanyl, thiopentone sodium or ketamine, and maintained with fentanyl (50–100 µg/kg) combined with ketamine infusion (2 mg/kg per h) in some patients. Isoflurane or halothane was administered as necessary. In patients requiring open heart-surgery cardiopulmonary bypass (CPB) was established with a pediatric hollow membrane oxygenator, a cardiotomy reservoir and a roller pump. Blood flow during CPB was 2.4 l/min per m2 at 37°C; during hypothermia, the flow was reduced according to temperature to a minimum of 0.8 l/min per m2 at 15°C. DHCA 15–18°C was used when required to accomplish adequate conditions for the procedure. Cooling time was at least 20 min before DHCA. Low-flow CPB was not used. The acid-base status was managed with the alpha-stat protocol. The pump prime solution consisted of crystalloid, albumin, and fresh whole blood. The hematocrit was adjusted to 25%, and increased during rewarming with hemofiltration to at least 30%, adding fresh whole blood as necessary. For myocardial preservation, cold (+4°C) blood cardioplegic solution (30 ml/kg) was given immediately after the aorta was cross-clamped; additional doses (10 ml/kg) were given every 20 min. A final dose of warm cardioplegic solution (300 ml/m2), with 2 mmol/100 ml aspartate and 2 mmol/100 ml glutamate, was infused immediately before aortic declamping.

Postoperative management in the PICU was primarily directed by anaesthesiologists. However, paediatric cardiologists and especially cardiac surgeons participated actively in the postoperative care. Only a few patients were extubated in the operating theatre. Most patients received time-cycled pressure-limited mechanical ventilatory support, with subsequent weaning using intermittent mandatory ventilation and continuous positive airway pressure before extubation. Packed red cells and 4% albumin were used to replace blood loss from the surgical drains. Fresh frozen plasma and platelets were given as needed. Inotropic infusions were used to maintain adequate blood pressure and cardiac output. The level of monitoring of the patients varied according to the patients condition and type of the operation and, in addition to direct arterial pressure, EKG, and pulse oximetry, could include central venous pressure, pulmonary artery pressure and left atrial pressure monitoring. Epicardial leads were placed intraoperatively in the right atrial and ventricular myocardium to allow temporary cardiac pacing if needed. Peritoneal dialysis was used in patients with renal failure. Postoperative pain and sedation were managed with intra-venous morphine infusion and bolus doses. Oral or rectal administered chloral hydrate or intravenous benzodiazepines were also used quite commonly.

At the time of data collection, an on-call attending or resident anaesthesiologist was immediately available to manage cardiac arrests in the PICU, assisted by nurses. Open-chest CPR (OC-CPR) was provided by an anesthesiologist and a surgeon, assisted by nurses. The treatment of paediatric cardiac arrest conformed to the current guidelines issued by the American Heart Association [13]. The nursing staff was trained in basic life support, the physicians were responsible for paediatric advanced life support (PALS) procedures.

Cardiorespiratory arrest was defined as the absence of consciousness, apnea, and lack of palpable pulses in major arteries. CPR was also initiated in patients with bradycardia and clinical signs of poor tissue perfusion. We included in this study all patients who received external cardiac compressions or OC-CPR, and those who fulfilled the criteria for cardiopulmonary arrest and were defibrillated. Patients who only received resuscitation drugs or positive pressure ventilation, or who had received CPR in the operating theater, were not included. If the patient had had multiple episodes of in-hospital CPR, only the first event that met the study criteria was included. Thus, eight patients (five of whom died in the PICU) who had received successful CPR in the OR before arriving to PICU were not analyzed further. The recommended guidelines for uniform reporting on PALS [14] were used, whenever possible. Hospital charts of six patients, who possibly had received CPR, were not found.

Altogether, we identified 82 patients in whom CPR was attempted or who were declared dead without attempted resuscitation. Those 34 (41.5 %) patients in whom CPR was not initiated were included only in the evaluation of the incidence of CA and were excluded from further analysis. In the non-CPR group, one patient was declared brain dead and 33 deaths occurred after a decision to withhold resuscitation attempts because of medical futility. Most of these decisions were based on refractory circulatory compromise caused by complex congenital heart anomaly, low cardiac output syndrome, disseminated intravascular coagulation or sepsis.

The outcome of CPR was measured by calculating primary survival, survival for 24 h, survival to hospital discharge, and survival 1 year after discharge. The neurological status of the survivors was evaluated from the hospital records before cardiac arrest and at discharge using the Pediatric Overall Performance Category Scale (POPC) [14]. The POPC-scale classifies the quality of life into six categories: good, mild disability, moderate disability, severe disability, coma/vegetative state, and death. Favorable outcome at the time of discharge was defined as a POPC-classification reflecting no more than mild disability. Results are expressed as mean±SD or median values (range). Analysis of variance was used for the statistical comparison of data. A posteriori testing was performed with Tukey's test. Non-normally distributed data were compared with the Kruskall–Wallis test followed by Mann–Whitney U test. In addition, Fisher's exact test was used for the statistical comparison of nominal data. Differences were considered statistically significant if P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
During the 5-year study period, 1399 open- and closed heart operations were performed at the HCA. We identified 82 children, who had sustained a cardiopulmonary arrest or received CPR for life-threatening hypotension or bradycardia in the PICU after a corrective or palliative cardiovascular operation. The incidence of CA was highest after operations for hypoplastic left heart syndrome (HLHS) (2/4) and truncus arteriosus (5/12) (Table 2). Operations performed on patients who did not sustain CA in the PICU were not included in Table 2. The primary etiologies of these 284 operations were atrial septal defect (136), sub or supravalvular aortic stenosis (23), partial atrioventricular septal defect (22), and pulmonary atresia with intact ventricular septum (18). During the 5-year study period, the incidence of CA in the PICU was 5.9% (82/1399) for all the operations, 3.6% (18/496) for closed heart operations, 4.9% (40/814) for intra-cardiac surgery without DHCA, and 27% (24/89) for intra-cardiac operations involving DHCA. Thirty-three per cent of patients with CA arrested during the first 24 postoperative h. The incidence of cardiac arrest in the first 24 h was highest between 9 and 12 h from the operation (Fig. 1). The median time from the end of the operation to cardiopulmonary arrest in PICU was 1.1 days in resuscitated patients and 9.6 days in the patients who were declared dead without attempted resuscitation (P<0.001).


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  		Table 2. Etiologies of congenital heart diseases in patients who sustained cardiac arrest in PICU after a corrective or palliative cardiovascular operationa

 


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  		Fig. 1. Number of patients experiencing cardiac arrest in the first postoperative 24 h as a function of the time.

 
The immediate causes of CA in the 48 patients who received CPR were mainly cardiac (Table 3). Pulmonary hypertension usually occurred in patients with atrioventricular septal defect and trisomy-21. Airway obstruction led to CA in five patients, four of whom had severe tracheitis. The initial cardiac rhythm in the 48 resuscitated children was ventricular fibrillation/-tachycardia (VF/VT) in three patients (6.3%) In the remaining 45 patients, poor perfusion pressure (42%), bradycardia (29%) or asystole (29%) triggered CPR. Spontaneous circulation returned in 27 of the 48 resuscitated patients (56%); 18 of these patients died later during the same hospital admission. Twenty-five per cent of the primary survivors received CPR at least twice. Nine patients (19%) survived to be discharged; and they all were alive 1 year after discharge. At discharge, six of the nine survivors had a favorable outcome with no or mild disability by POPC-classification. Thirty-five of the 48 resuscitated patients received open-chest-CPR, five of these (14%) were alive 1 year after discharge compared to four survivors out of 13 patients (31%) of those who received only external CPR.


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  		Table 3. The immediate causes of cardiac arrest in 48 patients whom CPR was attempteda

 
There were no long term survivors among patients who arrested after the third postoperative day (Fig. 2). In addition to the 73 of 1399 postoperative patients who died in the PICU, five patients who had been successfully resuscitated in the OR, died in the PICU, bringing the total postoperative mortality to 5.6%.



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  		Fig. 2. Number of patients in whom CPR was attempted as a function of the time (days). Black bars represent non-survivors and grey bars survivors at 1 year from CPR.

 
Preoperative use of mechanical ventilation (P=0.03), prostaglandin E1 (P=0.001), and inotropic agents (P=0.04) was significantly more frequent among patients in the study group than in the control groups (Table 1). Patients in whom CPR was attempted were younger than the 1994 controls (P<0.04), had longer mean aortic-cross-clamp times (P<0.0001) and cardiopulmonary bypass times (P<0.0002) (Table 1). Patients who received CPR had also higher number of inotropic infusions upon leaving the operating room (P<0.0001); however, only the dose of dopamine was significantly higher (P=0.02) than in the 1994 controls (Table 1). Patients who received CPR had significantly longer DHCA times (P<0.0002) and required more inotropic support than patients in the DHCA control group (P<0.002). Although, CBP, ACC and DHCA times were significantly longer in patients with postoperative cardiac arrest (Table 1), no threshold value for a sudden increase in mortality could be identified (Fig. 3).



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  		Fig. 3. Cardiopulmonary bypass (CPB), aortic-cross-clamping (ACC) and deep hypothermic circulatory arrest (DHCA) times in patients having a cardiac arrest (CA) in PICU in comparison with patients who recovered without CA: 1994 controls and patients operated under DHCA. Horizontal lines are medians.

 
Of the 116 patients with hypoplastic left heart sydrome (HLHS) or univentricular heart (UVH) 51 had an univentricular repair resulting in parallel circulation. There was a significant difference in the incidence of CA among those patients with univentricular repair 16/116 (13.8%) compared to patients with biventricular repair 66/999 (6.6%) (P<0.01). However, the number patients in whom CPR was attempted was too small for statistical comparison of outcome between patients with univentricular physiology (1 survivor/8 attempts) and biventricular physiology (8/44).The high incidence of CA after operations involving DHCA was mainly related to the complexity of congenital heart defects in patients requiring circulatory arrest. For example, the incidence of CA after arterial switch or Senning operations under DHCA for transposition of great arteries was 35% (12/34) compared to (6/86) when the same operations were performed without DHCA.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The Hospital for Children and Adolescents is nationally responsible for paediatric open heart surgery; hence the population in our study represents the natural spectrum and incidence of congenital heart disease among 5 million primarily Scandinavian inhabitants. Cardiac arrest in the PICU was associated with repair of severe congenital heart anomalies requiring preoperative mechanical ventilation and vasoactive infusions, prolonged aortic cross-clamping, circulatory arrest, cardiopulmonary bypass, and heavy postoperative inotropic support. The incidence and outcome of CPR in the PICU in this study is in accordance with previous in-hospital reports from mixed patient populations [7–10]. Rhodes et al. [12] reported a similar incidence of CA (6%) in infants after cardiovascular operations in the PICU, but the survival rate (41%) was much better than that (14–19%) seen in our study and in the subgroup analyses of postoperative cardiovascular patients in mixed PICU patient populations [9,15]. Also the incidence of VF/VT was much higher in Rhodes study [12] than in ours (41 vs. 6%), a fact that partly explains the better survival.

We used only the primary type of congenital cardiac defect for classification, to avoid breaking the patient population down to an unmanageably large number of groups. The observed mortality in the PICU (5.6%) with two surgeons performing all the operations was in line with the 5.9% mortality reported in 16 acute care hospitals from New York with annual pediatric cardiac surgery volumes of 100 or more and surgeons with annual volume 75 or more [16]. However, the incidence of cardiac arrest in PICU after palliative or corrective operations for HLHS and truncus arterious was somewhat higher than rates recently reported elsewhere [17,18]. During the study period, the Norwood procedure was started in a small scale in our unit, hence the small number of operations and survivors. Mortality risk for truncus arteriosus is highly dependent on the underlying anatomy. If truncus arteriosus is combined with interrupted aortic arch, truncal valve stenosis or regurgitation, coronary artery anomalies, or very low birth weight, mortality will be significantly higher than the less than 10% reported in uncomplicated cases [17]. However, excellent results have been recently reported even in patients with truncus arteriosus combined with truncal valve regurgitation or interrupted aortic arch [19]. In the present study, all patients with truncus arteriosus who did not survive had one or several of the following problems: preoperative cardiopulmonary failure requiring ventilatory and inotropic support, persistent pulmonary hypertension, or truncal valve insufficiency.

Cardiac index values have been shown to fall after admission to PICU in postoperative cardiovascular patients, but they usually return to normal within 9 h [11,20]. The high incidence of CA in the present study between 9 and 48 h after the operation, were mainly due to a sudden cardiac event or low cardiac output syndrome not responding to treatment.

Cardiac surgery is known to be a difficult area for outcome prediction [1]. Poor clinical condition and acidosis before surgery has previously been related to unfavorable outcome after repair of interrupted aortic arch [2]. Because of the retrospective nature of the study, we were not able to abstract postoperative serum lactate, pH or basic deficit comprehensively for the study and control groups. Therefore need for mechanical ventilatory support; inotropic agents, and prostaglandin E1 were used as indicators of the patients’ preoperative condition. The number of patients with these preoperative factors was significantly smaller in the control group of patients without DHCA who recovered without CA.

In the present study cardiac arrest in the PICU was associated with prolonged ACC, CBP and DHCA times. This is in line with the findings of Rady et al. [3] in which long CPB time (>140 min) and ACC time (>120 min) were predictors of postoperative mortality in elderly patients. Even in children, CBP time greater than 150 min has been an independent predictor of major adverse events in postoperative phase [11]. However, other studies have not confirmed these findings [4,21].

In the present study, those patients who experienced cardiac arrest in PICU had significantly longer DHCA times (53 vs. 32 min) than those patients who underwent DHCA, but did not arrest postoperatively. Furthermore, the incidence of CA in patients who were operated under DHCA was remarkably higher than in intra-cardiac surgery patients operated without DHCA (27 vs. 5.0%). Longer DHCA time has been earlier reported to be related to poorer postoperative neurological outcome [22,23]. Some authors [22,24] recommend, therefore, that circulatory arrest be limited to less than 35 to 45 min. However, Eke et al. [25] found no effect of DHCA times ranging from 42 to 70 min on neurological developmental outcome up to 2.5 years postoperatively. Although, DHCA has not been shown to be directly related to higher mortality, operations performed under DHCA are longer and usually more complex and require longer ACC time, which has been shown to be associated with damage to the myocardium [1,3].

Patients with CA had a significantly higher number of different inotropic infusions upon leaving the operating room, even though only dopamine was given in significantly higher doses to these patients compared with the 1994 controls. In adult cardiovascular patients, longer ACC time has been associated with greater need for inotropic agents [21] at the time of ICU admission, and significantly higher mortality [3]. However, when evaluating the effects of ACC, CPB and DHCA times and the level of inotropic therapy on the incidence of CA in PICU, the severity and operative complexity of congenital heart disease, patient's age, complications and cardioprotective methods must also be considered. The severity and complexity of congenital heart disease likely is the primary factor that influences postoperative outcome, and the factors related to ACC and extracorporeal circulation are mainly unavoidable consequences from that, assuming proper conduct of CPB and myocardial protection.

Univentricular repair was related to higher incidence of CA in the present study. However, the number of patients whom CPR was attempted was too small for statistical comparison of outcome between patients with univentricular and biventricular physiology. This contrasts with the findings of Rhodes et al. [12] indicating no difference in the outcome of resuscitation in postoperative patients with univentricular or biventricular physiology.

While respiratory compromise has been established as the leading cause of CA in children in general [13,14], the present study shows that the majority of resuscitations in postoperative cardiovascular patients are triggered by a cardiovascular event. However, the survival was much better in the patients with respiratory compromise. The absence of long term survivors among patients who arrested after the third postoperative day contrasts with earlier findings [12]. Open chest CPR (OC-CPR) has been shown to be physiologically superior to closed-chest CPR [26]. In this study those patients who received OC-CPR had a lower survival rate at 1 year from discharge than patients receiving external CPR. However, all patients in whom OC-CPR was attempted initially responded poorly to a short period of closed-chest CPR before reopening sternum, which reflects higher resistance to resuscitative efforts among these patients.

The present study is limited by its retrospective nature. Some hospital charts had incomplete information concerning the CPR event, therefore we were not able to collect all the data needed from these patients. Data from six patients could not be reviewed because their records had been misplaced. These patients died at HCA during the study period and may or may not have received CPR. Even though some additional cases of CPR may have been overlooked because no procedure code for CPR was used, we believe the effect of referral bias in this study is minimal.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
CA in postoperative cardiovascular patients is an uncommon event; the survival rate is comparable to those reported from mixed PICU patients. CA is associated with repair of severe congenital heart anomalies more likely to require preoperative mechanical ventilation and vasoactive agents, prolonged aortic cross-clamp time, circulatory arrest; and heavy postoperative inotropic support.


   Acknowledgments
 
This study was supported by the Foundation for Pediatric Research. The authors thank the staff from archives of Hospital for Children and Adolescents of Helsinki University Central Hospital for their valuable assistance in obtaining the medical records.


   Footnotes
 
Presented at The Third Congress of Pediatric Cardiac Intensive Care, Miami, FL, December 9–12, 1999.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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