Commentary
Expert Comments and Other Institutional Practices
Premal Trivedi, MD
Assistant Professor of Anesthesiology
Texas Children’s Hospital
Division of Pediatric Cardiovascular Anesthesiology
Baylor College of Medicine
“In their logical and practical approach to guide post-anesthetic disposition in patients with pulmonary hypertension, Drs. Chau and Gangadharan underscore two critical points: first, assessment of disease severity and related perioperative risk is evolving and in need of further study, and second, early pre-operative communication is essential to minimize complications and optimize patient outcomes.
While there is likely agreement over those patients who constitute both high and low perioperative risk, it is those patients in the intermediate risk category due to their disease state or planned procedure that are more challenging to assess. Based on the reviews provided in this article, there is still uncertainty as to what hemodynamic factors correlate with complications. And while it may make intuitive sense that certain procedural or anesthetic factors would increase risk, this is also uncertain. Pediatric cardiovascular anesthesiologists, given our extensive experience with these patients, are uniquely poised to identify such perioperative risk factors.
There is likewise agreement that advance communication among the referring pediatrician, anesthesiologist, and surgeon is useful in optimizing these patients and ensuring that the necessary resources are available prior to the procedure. Too often, this discussion occurs late on the morning of surgery or is altogether absent, resulting in delays, parental dissatisfaction, and avoidable complications. One can imagine, though, the challenge in attempting to organize such discussions in the days or weeks prior to surgery, particularly in large institutions with multiple referring pediatricians and surgeons and a constantly shifting surgical schedule.
One potential solution may be to develop a perioperative surgical home (PSH) for disease processes, like pulmonary hypertension, with high-risk profiles. The concept of a PSH entails the formation of a team whose goal is to manage a patient’s perioperative care from the decision to undergo surgery through to the post-discharge period.1,2 Such a team would ensure a standardized and best practice approach such that issues of optimization and the logistics of post-operative disposition could be determined well in advance.
At Texas Children’s, we use a process similar to the one suggested by Drs. Chau and Gangadharan to determine post-operative disposition; the patient’s medical risk is weighed along with the procedure’s and anesthetic’s risk to determine whether to admit and to what location. This occurs on a case-by-case basis, which commonly results in high-risk patients being admitted to the ICU, and low-risk patients being observed in the PACU with the possibility for discharge home. Those with intermediate-risk characteristics are generally admitted with final disposition based on the variables presented in this article.
While this method is useful in that it allows for flexibility given the spectrum of pulmonary hypertension, it does allow for variability in decision-making among different providers. With more robust data on perioperative risk factors, some of this subjectivity could likely be eliminated. Pre-operative discussion between the anesthesiologist and interventional specialist (surgeon, cardiologist, others) commonly occurs the day prior to the procedure if electively scheduled. Though this is sufficient for most of our patients, there are clearly some for whom this is inadequate, and for whom the idea of a PSH will be beneficial.”
References
- Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesthesia & Analgesia 2014;118:1126-30
- Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Pittet J. The Perioperative Surgical Home: How Anesthesiology Can Collaboratively Achieve and Leverage the Triple Aim in Health Care. Anesthesia & Analgesia 2014;118:1131-36
Viviane Nasr, MD
Assistant Professor
Division of Cardiac Anesthesia
Department of Anesthesiology, Perioperative and Pain Medicine
Boston Children’s Hospital
“At Boston Children’s Hospital, we do not follow a formal algorithm that would apply to all patients with PAH. Management of this high-risk patient population should be individualized and is based on the patient’s co-existing diseases and surgical procedure/intervention. Most patients will be admitted to the hospital overnight. The decision to admit to the ICU depends on the patient’s condition pre- and intra-operatively, the need for post-operative ventilation and the anticipated physiologic and hemodynamic changes after the procedure.”
Mark Twite, MA, MB, BChir, FRCP
Associate Professor
Director of Pediatric Cardiac Anesthesia
Department of Anesthesiology
Children's Hospital Colorado & University of Colorado, Denver
“Dr’s Chau and Gangadharan are to be congratulated on such an excellent article for the CCAS Newsletter. They address a very important issue on the post-operative care of patients with pulmonary hypertension. Table 2 is particularly helpful, summarizing the preoperative risk stratification of patients with PAH. While all of the listed factors are relevant, it is difficult to know the importance of each one in a particular patient. Usually the most concerning patient is the newly diagnosed patient with systemic pulmonary arterial pressures who is not yet on any therapy.
However, patients with lower risk factors can have a pulmonary hypertensive crisis, such is the unpredictable nature of the disease. The post-anesthesia disposition proposal in the article is sound advice and similar to how our institution manages these patients in the post-operative period. The two most important factors are probably good communication with the pulmonary hypertension team and involvement of an experienced cardiac anesthesiologist in the PACU care. Often the PH team has additional insights into the family situation which may be helpful, such as medication compliance, ability to respond to any change in their child and distance the family live from the hospital.
Evidence based guidelines may be very difficult for the congenital cardiac anesthesia community to develop, due to the lack of data. Expert consensus can certainly help but it is no replacement for a multidisciplinary collaborative approach to caring for these patients in the peri-operative period. This is something we should all embrace and lead the way.”
