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

ABSTRACT: 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.

SUBMITTER: Pasquali SK

PROVIDER: S-EPMC3444656 | biostudies-literature | 2012 Oct

REPOSITORIES: biostudies-literature

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

Pasquali Sara K SK Ohye Richard G RG Lu Minmin M Kaltman Jonathan J Caldarone Christopher A CA Pizarro Christian C Dunbar-Masterson Carolyn C Gaynor J William JW Jacobs Jeffrey P JP Kaza Aditya K AK Newburger Jane J Rhodes John F JF Scheurer Mark M Silver Eric E Sleeper Lynn A LA Tabbutt Sarah S Tweddell James J Uzark Karen K Wells Winfield W Mahle William T WT Pearson Gail D GD

The Journal of thoracic and cardiovascular surgery 20120612 4

<h4>Objectives</h4>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.<h4>Methods</h4>Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who ...[more]

PMID: 22698562

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Project description:The transfusion of stored RBCs decreases nitric oxide bioavailability, which may have an adverse effect on vascular function. We assessed the effects of RBC transfusion on coronary vascular function by evaluating the relationship between myocardial oxygen delivery and demand as evidenced by ST segment variability.DesignRetrospective case-control study.SettingNine-hundred seventy-three-bed pediatric hospital with a 54-bed cardiovascular ICU.PatientsSeventy-three neonates with hypoplastic left heart syndrome following the Norwood procedure, 38 with a Blalock-Taussig shunt and 35 with a right ventricle to pulmonary artery shunt.InterventionsRBC transfusion.Materials and main resultsHigh-frequency physiologic data were captured 30 minutes prior to the initiation of (baseline) and during the 120 minutes of the transfusion. A rate pressure product was calculated for each subject and used as an indicator of myocardial oxygen demand. Electrocardiogram leads (aVL, V1, II) were used to construct a 3D ST segment vector to assess ST segment variability and functioned as a surrogate indicator of myocardial ischemia. One-hundred thirty-eight transfusions occurred in the Blalock-Taussig shunt group and 139 in the right ventricle to pulmonary artery shunt group. There was no significant change in the rate pressure product for either group; however, ST segment variability progressively increased for the entire cohort during the transfusion, becoming statistically significant by the end of the transfusion. Upon subgroup analysis, this finding was noted with statistical significance in the Blalock-Taussig shunt group and trending toward significance in the right ventricle to pulmonary artery shunt group.ConclusionsWe found a significant increase in the ST segment variability and evidence of myocardial ischemia temporally associated with RBC transfusions in neonates following the Norwood procedure, specifically among those in the Blalock-Taussig shunt group, which may impact immediate and long-term outcomes.

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

Publications

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

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