Speeding Up Healing: How a Fast-Track Plan is Changing Kids’ Heart Surgery for the Better!

Hey everyone! Let me tell you about something pretty exciting we’ve been looking into in the world of paediatric cardiac surgery. You know, when little ones need heart operations, it’s a super stressful time for everyone – the kids, their families, and us, the medical teams. We’re always on the lookout for ways to make things smoother, safer, and get these brave little fighters back on their feet faster. That’s where something called an “interdisciplinary fast-track protocol” comes in. Sounds a bit fancy, right? But stick with me, it’s all about teamwork and smart planning!

So, What’s This “Fast-Track” Buzz All About?

You might have heard of “Enhanced Recovery After Surgery” programs, or ERAS for short. They’ve been around for a couple of decades, first making waves in things like colorectal surgery. The big idea is to use a whole bunch of different strategies before, during, and after an operation to cut down on the body’s stress response to surgery. Think of it as a pit-stop strategy in a race – every little optimization helps! The goals? Shorter hospital stays, especially in the Intensive Care Unit (ICU), without, and this is crucial, compromising safety or how well the surgery goes.

This ERAS thinking has been a hit in adult cardiac surgery, and more recently, we’ve started to see how it can help our littlest patients too. A key part of these “fast-track” plans is getting patients breathing on their own again (extubation) as soon as safely possible after surgery, ideally within 6 hours. Believe it or not, the idea of early extubation for kids after heart surgery isn’t brand new – some smart folks were reporting success with it way back in the 1980s! It was all about using resources wisely, like ICU beds, without any downside for the kids.

Modern anaesthesia has really helped push this forward. We’ve got nifty inhalational agents, opioids that wear off quickly, and muscle relaxants that don’t hang around too long. Plus, newer drugs like dexmedetomidine, an alpha-2 agonist, are real game-changers. They can help reduce the stress reactions to surgery, making it easier to extubate kids right there in the operating room (OR) or very soon after. Of course, deciding who’s a good candidate for this super-early extubation depends a lot on the whole team – surgeons, anaesthetists, ICU docs – and our hospital’s setup and experience.

Our Big Question: Does Fast-Track Really Work for Kids’ Heart Ops?

So, we rolled up our sleeves and decided to dig into this. We wanted to see if our own predefined fast-track protocol for paediatric cardiac surgeries was truly making a difference. Our main questions were:

• Could we get kids off the breathing machine (ventilator) sooner?
• Could we shorten their stay in the ICU?

And, just as importantly, we looked at other things like:

• Did it lead to more or fewer complications after surgery?
• What about the total time spent in the hospital?
• And the most critical one: did it affect mortality rates? (Spoiler: it didn’t, which is great news!)

We did what’s called a retrospective study. This means we looked back at data from patients treated at our university-affiliated heart centre. We focused on kids under 18 (but not brand-new babies needing heart surgery right away) who had congenital heart diseases of a certain complexity (RACHS-1 category I-III). These were kids undergoing operations to either fix their hearts or provide palliative care, all involving cardiopulmonary bypass (the heart-lung machine).

We took a group of patients treated with our Fast-Track Anaesthesia (FT) protocol between February 2020 and January 2022. This protocol wasn’t just about anaesthesia; it was an all-hands-on-deck approach involving careful patient selection, a standard anaesthesia and extubation plan, using transoesophageal echocardiography (TOE – like an ultrasound for the heart via the food pipe) during the op, and even a quick lung ultrasound before taking out the breathing tube.

The types of surgeries included things like fixing holes between heart chambers (VSDs, ASDs), Tetralogy of Fallot (TOF) repairs, and some single ventricle procedures like the Glenn or Fontan operations, provided they met certain criteria. We were careful to exclude kids with really high pressure in their lung arteries, emergency cases, or those who were already on a ventilator before surgery or had severe heart failure.

The Nitty-Gritty of Our Fast-Track Approach (and the Conventional Way)

To make a fair comparison, we needed a control group. So, we found patients who had similar surgeries but were managed with our conventional anaesthesia approach before we fully rolled out the fast-track system (from January 2018 to November 2021). Now, because these groups weren’t chosen randomly at the time, we used a clever statistical trick called “propensity score matching.” This helps to make the two groups as similar as possible in terms of things like age, size, type of surgery, etc., so we can be more confident that any differences we see are due to the fast-track protocol itself and not just because the groups were different to begin with. After matching, we had 118 patients in our Fast-Track (FT) group and 118 in the conventional (C) group.

So, what did our FT protocol involve?

• Teamwork for Selection: Not every child is a candidate, so careful selection is key.
• Pre-Op Prep: Limited fasting (6 hours for solids, clear fluids allowed closer to surgery), and a little something (oral midazolam) to ease anxiety.
• Smart Anaesthesia: We used balanced anaesthesia, often with ketamine or etomidate for little ones and propofol for older kids. Remifentanil, a short-acting painkiller, was a mainstay. We also brought in dexmedetomidine during induction and continued it after surgery. Sevoflurane, an inhalational agent, helped maintain anaesthesia.
• Monitoring Galore: Besides the usual ECG and pulse oximetry, we used cerebral oximetry (to check brain oxygen levels), invasive blood pressure lines, and central venous catheters, all placed with ultrasound guidance.
• During Surgery: Antibiotics before the first cut, tranexamic acid to reduce bleeding, careful temperature monitoring, and hourly blood gas checks. The heart-lung machine (CPB) was used as standard. We aimed for specific haemoglobin levels for blood transfusions.
• Getting Off the Machine: TOE was crucial to check the surgical repair and heart function before coming off CPB.
• The Extubation Decision: This was a team call with surgeons and intensivists. We looked for good blood gases, good lung function (checked with a lung ultrasound!), stable heart function on TOE, no major bleeding, and the child being warm enough.
• Pain Control: A multi-pronged approach using piritramide (an opioid) and metamizole (a non-opioid). We also watched out for and treated emergence delirium.

The conventional management was a bit different. For instance, they often used midazolam during anaesthesia maintenance, didn’t routinely use dexamethasone (for nausea) or dexmedetomidine. Pancuronium, a longer-acting muscle relaxant, was used. All these patients were transferred to the PICU still on the ventilator and sedated, with extubation happening later in the ICU.

What Did We Actually Find? The Exciting Results!

Okay, drumroll, please! After all that careful matching and analysis, what did the numbers tell us?
Well, the FT protocol made a BIG difference in how long kids needed the breathing machine. We’re talking a median of just 83 minutes for the FT group compared to a whopping 1150 minutes for the conventional group. That’s a huge reduction (p<0.001)!

And what about ICU time? The FT group spent significantly less time in the ICU: a median of 70 hours versus 94 hours for the C-group (p=0.02). That’s nearly a whole day less in intensive care, which is fantastic for the kids and for hospital resources.

Interestingly, while the total hospital stay was a bit shorter for the FT group (11.5 days vs. 13.5 days), this difference wasn’t statistically significant (p=0.08). Maybe something to look into more in the future!

But here’s where it gets even better. The FT group had:

• Fewer infections: 2.5% in FT vs. 9.3% in C-group (p=0.03).
• Less stridor (that noisy breathing some kids get after the tube comes out): 3.4% vs. 16% (p<0.001).
• Less pericardial effusion (fluid around the heart): 2.5% vs. 12.7% (p=0.003).
• Lower incidence of delirium: 6.8% vs. 17% (p=0.016).

And the absolute best news? Postoperative mortality was 0% in both groups. So, all these benefits came without any increased risk. Pretty neat, huh?

In our FT group, out of 118 patients, a fantastic 96 (that’s 81%!) were extubated right there in the operating room (we call this OTE – On-Table Extubation). Another 19 (16%) were extubated in the PICU within 6 hours. So, in total, 115 out of 118 kids (a massive 97%) were extubated early! This is a big deal compared to some earlier studies that reported lower early extubation rates, often because they didn’t have such a strict, predefined protocol and multidisciplinary buy-in.

Diving Deeper into the ‘Why’: What Made the Difference?

It seems our combination of a multidisciplinary approach, careful patient selection, and specific anaesthesia management really paid off. Many parts of our FT protocol line up with established guidelines. Things like multimodal pain therapy (using different types of pain relief), using anaesthetic adjuvants to cut down on nausea and delirium, using TOE to check the repair right away, and lung-protective ventilation strategies all play a part.

The choice of anaesthetic agents is super important. We used sevoflurane, which has some known heart-protective effects. Remifentanil, our go-to opioid for induction and maintenance, is known to help with quicker ventilation times. And then there’s dexmedetomidine – what a star! It helps reduce stress, keeps things haemodynamically stable, and can really help with getting that breathing tube out sooner and reducing delirium. We saw less delirium in our FT group, and dexmedetomidine likely played a big role there. Delirium can be a real problem after kids’ heart surgery, so anything that reduces it is a win.

Early extubation itself has a cascade of benefits. Less time on a ventilator means less risk of ventilator-associated pneumonia (though we didn’t specifically see a difference in pneumonia, fewer infections overall is a plus!). It also means kids can start moving around sooner, which is great for recovery. We even used lung ultrasound before extubation to make sure the lungs were looking good – checking for things like atelectasis (collapsed lung areas) or fluid, and ensuring the diaphragm was moving well. This little check gives us extra confidence.

We also found that our FT group needed less inotropic support (medicines to help the heart pump) and less volume (fluids), and even fewer red blood cell transfusions. This all points to a smoother recovery with less stress on the body. The reduction in stridor is also a big one – it’s uncomfortable for the kids and worrying for parents. Getting the tube out sooner clearly helps here.

It’s interesting to think about specific patient groups too. For example, early extubation seems to be particularly beneficial for kids undergoing Fontan surgery or TOF repairs. Getting them breathing on their own can actually help their heart and lung function in these specific situations.

A Few Caveats and What’s Next

Now, I know what you’re thinking – every study has its limits, and ours is no exception. Because we looked back at data (retrospective study), there’s always a chance of some biases creeping in, even though we tried our best to control for them with propensity score matching. It’s also a “before-and-after” type comparison in a way, which can make it tricky to be 100% sure about cause and effect.

So, what’s the takeaway? Our study strongly suggests that using a well-defined, interdisciplinary fast-track protocol for selected paediatric cardiac surgical patients is a winner. It significantly cuts down ventilation time and ICU stays, and reduces several postoperative complications, all while keeping our little patients safe.

The key really seems to be that predefined protocol and strict patient selection. It’s not just about one magic bullet, but a whole coordinated effort. Of course, more research, especially randomized controlled trials (the gold standard!), would be fantastic to really cement these findings and see if we can extend these benefits to even more complex cases or even our tiniest neonatal patients. But for now, we’re pretty chuffed with how this fast-track approach is helping us care for these amazing kids!

Source: Springer