|Year : 2015 | Volume
| Issue : 4 | Page : 463-468
Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis
Mohamed Saleh MD
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Abbasia, Cairo, Egypt
|Date of Submission||20-Sep-2015|
|Date of Acceptance||01-Nov-2015|
|Date of Web Publication||29-Dec-2015|
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Abbasia, Cairo 11566
Source of Support: None, Conflict of Interest: None
Enhanced recovery after surgery is a multimodal, multidisciplinary, evidence-based approach, aiming to control postoperative pathophysiology and rehabilitation. The aim of this article is to review current literature in pediatric cardiac practice, implementing the ERAS approach, to identify peri-operative strategies that are associated with enhanced recovery after pediatric cardiac surgery.
Keywords: Enhanced recovery, pediatric cardiac anesthesia, postoperative pathophysiology, postoperative rehabilitation
|How to cite this article:|
Saleh M. Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis. Ain-Shams J Anaesthesiol 2015;8:463-8
|How to cite this URL:|
Saleh M. Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2021 Apr 12];8:463-8. Available from: http://www.asja.eg.net/text.asp?2015/8/4/463/172664
| Introduction|| |
Enhanced recovery after surgery (ERAS) was introduced in 1997 by Henrik Kehlet, a gastrointestinal surgeon from Denmark. It is a multimodal, multidisciplinary, evidence-based approach, which aims to control postoperative pathophysiology and rehabilitation. It provides perioperative care that minimizes stress/surgical trauma reaction, aiming to reduce postoperative morbidity, and improves and accelerates recovery, leading to a shorter length of hospital stay. All of these factors have an economic advantage in terms of better utilization of resources and cost-benefit ratio. ERAS was originally described in colorectal surgery, but it has expanded to include other surgical specialties , .
The aim of this article was to review current literature in pediatric cardiac practice, implement the ERAS approach, and identify perioperative strategies that are associated with enhanced recovery after pediatric cardiac surgery.
Enhanced recovery after surgery in pediatric cardiac practice
Early tracheal extubation after pediatric cardiac surgery is not a new concept, but has received renewed attention with the evolution of ERAS. Early extubation after pediatric cardiac surgery was first proposed by Barash et al.  in 1980. In 1984, Schuller et al.  reported that early extubation after pediatric cardiac surgery has minimal risk in carefully selected patients. However, early extubation and ERAS are not synonymous. Early extubation is an element component of ERAS program.
In 2010, a protocol was published from Great Ormond Street Hospital that describes a clinical perioperative pathway in which pediatric cardiac patients rapidly progress from preoperative preparation, through cardiac surgery and postoperative care. The protocol includes admission to hospital on the morning of surgery, reduced postoperative ventilation time, same-day discharge from ICU to high dependency unit in the ward, optimal analgesia, early liberalization from fluids and early mobilization, and earlier discharge from hospital. Greater experience with this type of protocol leads to reduction in the length of hospital stay  .
The benefit of implementation of ERAS in pediatric cardiac practice is decreased hospital stay, decreased overall medical costs, and better utilization of resources without affecting patient safety  . In the current era of limited resources and cost-benefit consideration, such protocol would be appreciated.
In this article, we have reviewed current literature in pediatric cardiac practice, implemented the ERAS approach, and identified the following perioperative strategies that are associated with enhanced recovery after pediatric cardiac surgery [Figure 1].
|Figure 1: Implementation of enhanced recovery after surgery (ERAS) in pediatric cardiac practice|
Click here to view
Appropriate patient selection is important for successful ERAS program , . Patient selection criteria included the following:
- Age more than 6 months and weight more than 10 kg, as many studies demonstrated that there is an increased rate of reintubation in younger infants.
- Presence of simple cardiac lesion, including atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), and coarctation of the aorta, in addition to having undergone certain pediatric cardiac procedure, including Glenn and Fontan shunt. Children with cardiac lesions, including large left-to-right shunts and moderate-to-severe pulmonary hypertension, and those with complicated cardiac lesions, including atrioventricular canal, truncus arteriosus, D-transposition of the great vessels, total anomalous pulmonary venous return, and hypoplastic left heart syndrome, were excluded.
- Completely healthy preoperative condition: Patients with preoperative comorbidities, including preoperative respiratory compromise, preoperative congestive heart failure, and failure to thrive, were excluded.
Adoption of specialized preanesthesia evaluation for pediatric patients scheduled for cardiac surgery allows admission to hospital on the day of surgery with significant reduction in surgical cancellation or delay from abnormal laboratory tests, upper respiratory infections, or other intervening events, as well as significant reduction in the length of admission ,, .
Optimization of patient's condition
All medications should be continued up to the time of surgery, except diuretics and digoxin, which should be stopped 24 h before surgery. Treatment of anemia and optimization of chest condition are of paramount importance , .
Shortened preanesthetic fasting interval
Children scheduled for cardiac surgery may be allowed to drink clear liquids up to 2 h before induction of anesthesia without adversely affecting residual gastric fluid volume and gastric fluid pH. The aim of shortening preanesthetic fasting interval is to avoid preoperative dehydration and hypoglycemia, and to maximize patient and parent satisfaction. Avoiding preoperative dehydration and preserving intravascular volume improve hemodynamic response during inhalation induction of anesthesia and facilitate vascular access. Avoiding preoperative hypoglycemia through ingestion of dextrose-containing fluids maintain plasma glucose levels, especially in infants and young children with limited glycogen stores , .
Clinically significant decrease in SpO 2 and rise in PaCO 2 were observed in children with congenital heart disease following standardized intramuscular premedication with morphine, scopolamine, and secobarbital. Hypoxia and hypercarbia are detrimental in these patients, as they cause acute increase in pulmonary artery pressure and pulmonary vascular resistance. Oral midazolam was demonstrated to be a safe alternative for such protocol ,, .
Short-acting anesthetic agents
For many years, a high-dose opioid technique was considered to be beneficial in improving outcome in complex surgery for congenital heart disease (CHD). It was shown that a high-opioid technique can blunt the stress response to surgery and cardiopulmonary bypass and was thought to provide superior hemodynamic stability ,, .
However, ERAS program requires an anesthetic technique that allows safe early extubation within a few hours in the ICU. Therefore, a high-dose opioid technique is typically not suitable for this approach ,, . It has been demonstrated that the use of moderate doses of short-acting or intermediate-acting opioid supplemented with inhalational anesthetic can reduce the duration of mechanical ventilation and intensive care stay , .
Neuraxial blockade might be useful in minimizing intravenous opioid administration. Caudal or intrathecal opioid has been shown to blunt the stress response to surgery and cardiopulmonary bypass and improve postoperative analgesia in pediatric cardiac patients ,, .
Although there is no doubt that neuraxial blockade provides long-lasting analgesia with significant opioid-sparing effect, there is controversy as regards the safety and benefits of such technique ,, .
Minimally invasive surgical approach
Minimally invasive surgical approaches facilitate ERAS program. Limited skin incisions with median sternotomy, limited sternotomy, right anterior minithoracotomy, and video-assisted endoscopic technique have superior cosmetic results without affecting morbidity and offer more psychological and social satisfaction for the patients ,,,,,, .
The recent change to normothermic cardiopulmonary bypass and normothermic cardioplegia is gaining popularity in pediatric cardiac practice. Normothermic cardiopulmonary bypass and intermittent normothermic blood cardioplegia are associated with higher spontaneous resumption of sinus rhythm, smaller increase in troponin I, improved hemodynamic stability, allowing early extubation of patients, and shorter duration of ICU stay ,,, .
The systemic inflammatory response resulting from extracorporeal circulation, surgical trauma, protamine, and ischemia-reperfusion injury causes humoral and cellular responses, leading to increased interstitial fluid and generalized capillary leak, and has a potential for multiple organ dysfunction syndrome ,, .
During pediatric cardiac operations, using either conventional or modified ultrafiltration removes excess fluid and inflammatory mediators. Several studies demonstrated that ultrafiltration increased arterial oxygen tension and lowered carbon dioxide tension after bypass, shortened intubation and mechanical ventilation times, and improved postoperative pulmonary compliance ,,, .
Perioperative steroid administration is a common practice in pediatric cardiac surgery to modulate the inflammatory response associated with cardiopulmonary bypass  . Intraoperative steroid administration was associated with a significant decrease in postoperative cardiac troponin levels and shorter durations of stay in intensive care and hospital ,, . The use of an additional preoperative dose resulted in further modulation of inflammatory response, with improvement in oxygen delivery, and reduction in duration of mechanical ventilation ,, .
Systemic nonopioid analgesic
Effective pain management and sedation without respiratory depression is a crucial issue during the postoperative period. Narcotic administration may cause respiratory depression as well as nausea, vomiting, and delayed alimentation , . The use of nonopioid analgesic ketorolac in the postoperative period for pain control has been reported to be effective and safe in several studies ,,,, .
Parasternal intercostal nerve block
Parasternal intercostal block is a simple, safe, and effective technique for postoperative analgesia in pediatric patients undergoing cardiac surgery through median sternotomy. It resulted in less postoperative pain, reduced the requirement for postoperative opioids, and allowed early tracheal extubation  .
Continuous incisional infusion of local anesthetics
Continuous incisional infusion of local anesthetics is another simple, safe, and effective technique for postoperative analgesia in pediatric patients undergoing cardiac surgery through median sternotomy. It reduced postoperative analgesic requirement and sedative administration  .
Dexmedetomidine is a selective a-2 adrenergic receptor agonist with sedative, analgesic, and anxiolytic properties , . The use of dexmedetomidine in pediatric patients after cardiac surgery has been demonstrated to be well tolerated in intubated and nonintubated children. Favorable effects of dexmedetomidine include blunting sympathetic stress response through reduction of endogenous catecholamine release and decrease in intraoperative anesthetic, as well as postoperative analgesic requirements ,,, . However, dexmedetomidine did not significantly affect the postoperative course of children as measured by success of early extubation, duration of mechanical ventilation, and length of ICU stay  .
Avoid fluid overload
Fluid overload in pediatric patients after cardiac surgery may lead to multiple organ dysfunction syndrome  . Moreover, pediatric patients undergoing cardiac surgery are at risk for acute kidney injury. Chan et al.  demonstrated that the risk was associated with long cardiopulmonary bypass duration, low cardiac output syndrome, and total circulatory arrest. The cause-effect relationship between acute kidney injury and fluid overload has been demonstrated in either directions  . Several studies showed that fluid overload was associated with impaired oxygenation and poor outcomes ,,, .
It has been demonstrated that greater intraoperative and early postoperative blood transfusion emerged as a risk factor for longer duration of mechanical ventilation and prolonged hospitalization and was associated with increased incidence of infections in children after cardiac surgery ,, .
Hyperglycemia is common among pediatric patients after cardiac surgery. Severe hyperglycemia has been associated with increased morbidity and mortality rates ,,, . A conventional management (no insulin, no glucose) is satisfactory in most patients. However, insulin may be considered for small neonates with complex congenital heart surgery  .
Several studies have demonstrated that early enteral feeding decreases postoperative complications, accelerates wound healing process, decreases the cost of hospitalization, and improves quality of life ,,, . However, feeding difficulties are common following pediatric cardiac surgery. Risk factors for feeding difficulties include increased risk adjustment for congenital heart surgery score (RACHS score) and prolonged postoperative intubation , . The use of a standardized enteral feeding protocol reduced the incidence of necrotizing enterocolitis, enabled high-risk infants to achieve recommended daily calories earlier in their postoperative course, and also decreased the duration of total parenteral nutrition use , .
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606-617.
Kehlet H. Multimodal approach to postoperative recovery. Curr Opin Crit Care 2009; 15:355-358.
Barash PG, Lescovich F, Katz JD, Talner NS, Stansel HCJr. Early extubation following pediatric cardiothoracic operation: a viable alternative. Ann Thorac Surg 1980; 29:228-233.
Schuller JL, Bovill JG, Nijveld A, Patrick MR, Marcelletti C. Early extubation of the trachea after open heart surgery for congenital heart disease. A review of 3 years' experience. Br J Anaesth 1984; 56:1101-1108.
Howard F, Brown KL, Garside V, Walker I, Elliott MJ. Fast-track paediatric cardiac surgery: the feasibility and benefits of a protocol for uncomplicated cases. Eur J Cardiothorac Surg 2010; 37:193-196.
Fernandes AM, Mansur AJ, Caneo LF, Lourenco DD, Piccioni MA, Franchi SM, et al.
The reduction in hospital stay and costs in the care of patients with congenital heart diseases undergoing fast-track cardiac surgery. Arq Bras Cardiol 2004; 83:27-34. 18-26
Lake CL. Fast tracking the paediatric cardiac surgical patient. Paediatr Anaesth 2000; 10:231-236.
Lake CL. Fast tracking in paediatric cardiac anaesthesia: an update. Ann Card Anaesth 2002, 5:203-208.
Flynn BC, de Perio M, Hughes E, Silvay G. The need for specialized preanesthesia clinics for day admission cardiac and major vascular surgery patients. Semin Cardiothorac Vasc Anesth 2009; 13:241-248.
Flynn BC, Silvay G. Value of specialized preanesthetic clinic for cardiac and major vascular surgery patients. Mt Sinai J Med 2012; 79:13-24.
Van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ, Grobbee DE. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002, 94:644-649.
Nicolson SC, Dorsey AT, Schreiner MS. Shortened preanesthetic fasting interval in pediatric cardiac surgical patients. Anesth Analg 1992; 74:694-697.
Cook-Sather SD, Litman RS. Modern fasting guidelines in children. Best Pract Res Clin Anaesthesiol 2006; 20:471-481.
DeBock TL, Davis PJ, Tome J, Petrilli R, Siewers RD, Motoyama EK. Effect of premedication on arterial oxygen saturation in children with congenital heart disease. J Cardiothorac Anesth 1990; 4:425-429.
Alswang M, Friesen RH, Bangert P. Effect of preanesthetic medication on carbon dioxide tension in children with congenital heart disease. J Cardiothorac Vasc Anesth 1994; 8:415-419.
Masue T, Shimonaka H, Fukao I, Kasuya S, Kasuya Y, Dohi S. Oral high-dose midazolam premedication for infants and children undergoing cardiovascular surgery. Paediatr Anaesth 2003; 13:662-667.
Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992; 326:1-9.
Hickey PR, Hansen DD. High-dose fentanyl reduces intraoperative ventricular fibrillation in neonates with hypoplastic left heart syndrome. J Clin Anesth 1991; 3:295-300.
Hansen DD, Hickey PR. Anesthesia for hypoplastic left heart syndrome: use of high-dose fentanyl in 30 neonates. Anesth Analg 1986; 65: 127-132.
Mittnacht AJ, Hollinger I. Fast-tracking in pediatric cardiac surgery - the current standing. Ann Card Anaesth 2010; 13:92-101.
Preisman S, Lembersky H, Yusim Y, Raviv-Zilka L, Perel A, Keidan I, Mishaly D. A randomized trial of outcomes of anesthetic management directed to very early extubation after cardiac surgery in children. J Cardiothorac Vasc Anesth 2009; 23:348-357.
Yamasaki Y, Shime N, Miyazaki T, Yamagishi M, Hashimoto S, Tanaka Y. Fast-track postoperative care for neonatal cardiac surgery: a single-institute experience. J Anesth 2011; 25:321-329.
Humphreys N, Bays SM, Parry AJ, Pawade A, Heyderman RS, Wolf AR. Spinal anesthesia with an indwelling catheter reduces the stress response in pediatric open heart surgery. Anesthesiology 2005; 103:1113-1120.
Hammer GB, Ramamoorthy C, Cao H, Williams GD, Boltz MG, Kamra K, Drover DR. Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery. Anesth Analg 2005; 100:1283-1288.
Rojas-Perez E, Castillo-Zamora C, Nava-Ocampo AA. A randomized trial of caudal block with bupivacaine 4 mg x kg-1 (1.8 ml x kg-1) plus morphine (150 microg x kg-1) vs general anaesthesia with fentanyl for cardiac surgery. Paediatr Anaesth 2003; 13:311-317.
Leyvi G, Taylor DG, Reith E, Stock A, Crooke G, Wasnick JD. Caudal anesthesia in pediatric cardiac surgery: does it affect outcome? J Cardiothorac Vasc Anesth 2005; 19:734-738.
Holtby H. Con: regional anesthesia is not an important component of the anesthetic technique for pediatric patients undergoing cardiac surgical procedures. J Cardiothorac Vasc Anesth 2002; 16:379-381.
Rosen DA, Rosen KR, Hammer GB. Pro: regional anesthesia is an important component of the anesthetic technique for pediatric patients undergoing cardiac surgical procedures. J Cardiothorac Vasc Anesth 2002; 16:374-378.
Del Nido PJ. Minimal incision congenital cardiac surgery. Semin Thorac Cardiovasc Surg 2007; 19:319-324.
Mishaly D, Ghosh P, Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach. Ann Thorac Surg 2008; 85:831-835.
Vida VL, Padalino MA, Boccuzzo G, Veshti AA, Speggiorin S, Falasco G, Stellin G. Minimally invasive operation for congenital heart disease: a sex-differentiated approach. J Thorac Cardiovasc Surg 2009; 138:933-936.
Dave HH, Comber M, Solinger T, Bettex D, Dodge-Khatami A, Pretre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. Eur J Cardiothorac Surg 2009; 35:864-869. discussion 869-870.
Soukiasian HJ, Fontana GP. Surgeons should provide minimally invasive approaches for the treatment of congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005; 8:185-192.
Gil-Jaurena JM, Zabala JI, Conejo L, Cuenca V, Picazo B, Jimenez C, et al.
Minimally invasive pediatric cardiac surgery. Atrial septal defect closure through axillary and submammary approaches. Rev Esp Cardiol 2011; 64:208-212.
Wang Q, Li Q, Zhang J, Wu Z, Zhou Q, Wang DJ. Ventricular septal defects closure using a minimal right vertical infraaxillary thoracotomy: seven-year experience in 274 patients. Ann Thorac Surg 2010; 89: 552-555.
Durandy YD, Hulin SH. Normothermic bypass in pediatric surgery: technical aspect and clinical experience with 1400 cases. ASAIO J 2006; 52:539-542.
Durandy Y, Hulin S. Intermittent warm blood cardioplegia in the surgical treatment of congenital heart disease: clinical experience with 1400 cases. J Thorac Cardiovasc Surg 2007; 133:241-246.
Pouard P, Mauriat P, Ek F, Haydar A, Gioanni S, Laquay N, et al.
Normothermic cardiopulmonary bypass and myocardial cardioplegic protection for neonatal arterial switch operation. Eur J Cardiothorac Surg 2006; 30:695-699.
Caputo M, Bays S, Rogers CA, Pawade A, Parry AJ, Suleiman S, Angelini GD. Randomized comparison between normothermic and hypothermic cardiopulmonary bypass in pediatric open-heart surgery. Ann Thorac Surg 2005; 80:982-988.
Brix-Christensen V. The systemic inflammatory response after cardiac surgery with cardiopulmonary bypass in children. Acta Anaesthesiol Scand 2001; 45:671-679.
Day JR, Taylor KM. The systemic inflammatory response syndrome and cardiopulmonary bypass. Int J Surg 2005; 3:129-140.
Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist. Anesthesiology 2002; 97:215-252.
Kuratani N, Bunsangjaroen P, Srimueang T, Masaki E, Suzuki T, Katogi T. Modified versus conventional ultrafiltration in pediatric cardiac surgery: a meta-analysis of randomized controlled trials comparing clinical outcome parameters. J Thorac Cardiovasc Surg 2011, 142:861-867.
Williams GD, Ramamoorthy C, Chu L, Hammer GB, Kamra K, Boltz MG, et al.
Modified and conventional ultrafiltration during pediatric cardiac surgery: clinical outcomes compared. J Thorac Cardiovasc Surg 2006; 132:1291-1298.
Gaynor JW. The effect of modified ultrafiltration on the postoperative course in patients with congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2003; 6:128-139.
Maluf MA. Modified ultrafiltration in surgical correction of congenital heart disease with cardiopulmonary bypass. Perfusion 2003; 18:61-68.
Checchia PA, Bronicki RA, Costello JM, Nelson DP. Steroid use before pediatric cardiac operations using cardiopulmonary bypass: an international survey of 36 centers. Pediatr Crit Care Med 2005; 6: 441-444.
Clarizia NA, Manlhiot C, Schwartz SM, Sivarajan VB, Maratta R, Holtby HM, et al.
Improved outcomes associated with intraoperative steroid use in high-risk pediatric cardiac surgery. Ann Thorac Surg 2011; 91:1222-1227.
Checchia PA, Backer CL, Bronicki RA, Baden HP, Crawford SE, Green TP, Mavroudis C. Dexamethasone reduces postoperative troponin levels in children undergoing cardiopulmonary bypass. Crit Care Med 2003; 31:1742-1745.
Malagon I, Hogenbirk K, van Pelt J, Hazekamp MG, Bovill JG. Effect of dexamethasone on postoperative cardiac troponin T production in pediatric cardiac surgery. Intensive Care Med 2005; 31:1420-1426.
Schroeder VA, Pearl JM, Schwartz SM, Shanley TP, Manning PB, Nelson DP. Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression. Circulation 2003; 107:2823-2828.
Heying R, Wehage E, Schumacher K, Tassani P, Haas F, Lange R, et al.
Dexamethasone pretreatment provides antiinflammatory and myocardial protection in neonatal arterial switch operation. Ann Thorac Surg 2012; 93:869-876.
Wolf AR, Jackman L. Analgesia and sedation after pediatric cardiac surgery. Paediatr Anaesth 2011; 21:567-576.
Diaz LK. Anesthesia and postoperative analgesia in pediatric patients undergoing cardiac surgery. Paediatr Drugs 2006; 8:223-233.
Inoue M, Caldarone CA, Frndova H, Cox PN, Ito S, Taddio A, Guerguerian AM. Safety and efficacy of ketorolac in children after cardiac surgery. Intensive Care Med 2009; 35:1584-1592.
Dawkins TN, Barclay CA, Gardiner RL, Krawczeski CD. Safety of intravenous use of ketorolac in infants following cardiothoracic surgery. Cardiol Young 2009; 19:105-108.
Gupta A, Daggett C, Ludwick J, Wells W, Lewis A. Ketorolac after congenital heart surgery: does it increase the risk of significant bleeding complications? Paediatr Anaesth 2005; 15:139-142.
Gupta A, Daggett C, Drant S, Rivero N, Lewis A. Prospective randomized trial of ketorolac after congenital heart surgery. J Cardiothorac Vasc Anesth 2004; 18:454-457.
Moffett BS, Wann TI, Carberry KE, Mott AR. Safety of ketorolac in neonates and infants after cardiac surgery. Paediatr Anaesth 2006; 16:424-428.
Chaudhary V, Chauhan S, Choudhury M, Kiran U, Vasdev S, Talwar S. Parasternal intercostal block with ropivacaine for postoperative analgesia in pediatric patients undergoing cardiac surgery: a double-blind, randomized, controlled study. J Cardiothorac Vasc Anesth 2012; 26:439-442.
Tirotta CF, Munro HM, Salvaggio J, Madril D, Felix DE, Rusinowski L, et al.
Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery. Paediatr Anaesth 2009; 19:571-576.
Mason KP, Lerman J. Review article: dexmedetomidine in children: current knowledge and future applications. Anesth Analg 2011; 113:1129-1142.
Afonso J, Reis F. Dexmedetomidine: current role in anesthesia and intensive care. Rev Bras Anestesiol 2012; 62:118-133.
Mukhtar AM, Obayah EM, Hassona AM. The use of dexmedetomidine in pediatric cardiac surgery. Anesth Analg 2006; 103:52-56,
Klamt JG, de Andrade Vicente WV, Garcia LV, Ferreira CA. Effects of dexmedetomidine-fentanyl infusion on blood pressure and heart rate during cardiac surgery in children. Anesthesiol Res Pract 2010. doi:10.1155/2010/869049. http://www.hindawi.com/journals/arp/2010/869049/cta/
Chrysostomou C, Sanchez De Toledo J, Avolio T, Motoa MV, Berry D, Morell VO, Orr R, Munoz R. Dexmedetomidine use in a pediatric cardiac intensive care unit: can we use it in infants after cardiac surgery? Pediatr Crit Care Med 2009; 10:654-660.
Tobias JD, Gupta P, Naguib A, Yates AR. Dexmedetomidine: applications for the pediatric patient with congenital heart disease. Pediatr Cardiol 2011; 32:1075-1087.
Le KN, Moffett BS, Ocampo EC, Zaki J, Mossad EB. Impact of dexmedetomidine on early extubation in pediatric cardiac surgical patients. Intensive Care Med 2011; 37:686-690.
Ricci Z, Iacoella C, Cogo P. Fluid management in critically ill pediatric patients with congenital heart disease. Minerva Pediatr 2011; 63:399-410.
Chan KL, Ip P, Chiu CS, Cheung YF. Peritoneal dialysis after surgery for congenital heart disease in infants and young children. Ann Thorac Surg 2003; 76:1443-1449.
Bouchard J, Mehta RL. Fluid accumulation and acute kidney injury: consequence or cause. Curr Opin Crit Care 2009; 15:509-513.
Foland JA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, Rogers K, et al.
Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32:1771-1776.
Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R, Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001, 107:1309-1312.
Hayes LW, Oster RA, Tofil NM, Tolwani AJ. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394-400.
Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012; 13: 253-258.
Kipps AK, Wypij D, Thiagarajan RR, Bacha EA, Newburger JW. Blood transfusion is associated with prolonged duration of mechanical ventilation in infants undergoing reparative cardiac surgery. Pediatr Crit Care Med 2011; 12:52-56.
Salvin JW, Scheurer MA, Laussen PC, Wypij D, Polito A, Bacha EA, et al.
Blood transfusion after pediatric cardiac surgery is associated with prolonged hospital stay. Ann Thorac Surg 2011; 91:204-210.
Szekely A, Cserep Z, Sapi E, Breuer T, Nagy CA, et al.
Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations. Ann Thorac Surg 2009; 87:187-197.
Alaei F, Davari PN, Alaei M, Azarfarin R, Soleymani E. Postoperative outcome for hyperglycemic pediatric cardiac surgery patients. Pediatr Cardiol 2012; 33:21-26.
Preissig CM, Rigby MR, Maher KO. Glycemic control for postoperative pediatric cardiac patients. Pediatr Cardiol 2009; 30:1098-1104.
Yates AR, Dyke PCII, Taeed R, Hoffman TM, Hayes J, et al.
Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient. Pediatr Crit Care Med 2006; 7:351-355.
Falcao G, Ulate K, Kouzekanani K, Bielefeld MR, Morales JM, Rotta AT. Impact of postoperative hyperglycemia following surgical repair of congenital cardiac defects. Pediatr Cardiol 2008; 29:628-636.
Scohy TV, Golab HD, Egal M, Takkenberg JJ, Bogers AJ. Intraoperative glycemic control without insulin infusion during pediatric cardiac surgery for congenital heart disease. Paediatr Anaesth 2011; 21:872-879.
Bistrian BR. The who, what, where, when, why, and how of early enteral feeding. Am J Clin Nutr 2012; 95:1303-1304.
Powell-Tuck J. Perioperative nutritional support: does it reduce hospital complications or shorten convalescence? Gut 2000; 46:749-750.
Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut 2000; 46:813-818.
Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut 1996; 39:833-835.
Kogon BE, Ramaswamy V, Todd K, Plattner C, Kirshbom PM, Kanter KR, Simsic J. Feeding difficulty in newborns following congenital heart surgery. Congenit Heart Dis 2007; 2:332-337.
Cabrera AG, Prodhan P, Bhutta AT. Nutritional challenges and outcomes after surgery for congenital heart disease. Curr Opin Cardiol 2010; 25: 88-94.
Braudis NJ, Curley MA, Beaupre K, Thomas KC, Hardiman G, Laussen P, et al.
Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatr Crit Care Med 2009; 10: 460-466.
Del Castillo SL, McCulley ME, Khemani RG, Jeffries HE, Thomas DW, Peregrine J, et al.
Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med 2010; 11:373-377.