Anesthesia for Congenital Heart Surgery in Fortaleza

By Bruno Araújo Silva, MD
Anesthesiologist, Member of the Brazilian Society of Anesthesiologists

Ceará is one of the 26 states of Brazil, located on its northeast coast, with an estimated population of 9 million people. It is one of the poorest states of the country with a human development index well below the national average (0.759 vs 0.682). We have a relatively high infant mortality rate (about 14/100,000 habitants in 2016), especially within the neonatal period, with the congenital heart malformations contributing as a prominent cause of death.

The incidence of congenital heart disease (CHD) in Brazil is expected to be around 1%, based on data from populations with similar characteristics, which would be nearly 29,000 cases per year. However, according to the Brazilian System of Information about Live Births (SINASC), only about 1,680 cases per year are reported, which shows a huge underreporting, undoubtedly related to a failure in early diagnosis.

Our institution is a public hospital in the state's capital, Fortaleza, reference in the clinical and surgical treatment of adults and children with cardiovascular disease. We attend to patients from Ceará and from other states where the operations cannot be performed. In 2017, 249 patients with CHD were operated here, all younger than 18 years old (38 were <31 days of life). 45.8% of the children had a body mass index under the 5th percentile for age and sex. The incidence of surgical site infection was 8.4% and any major infection was present in 12.5% of the patients. Our in-hospital mortality rate was 11.7%, ranging from 0% (RACHS-1 category 1) to 40% (RACHS-1 categories 5 and 6).

The continuous underfunding is an important issue in our public health system, particularly in recent years. It is not uncommon to postpone a surgery due to a shortage of supplies. Depending on the supply needed, the waiting time for surgery can be long. These frequent and sometimes recurrent cancellations may delay the surgical treatment and compromise the outcome of patients. When we face urgent/emergent cases, the risk-benefit is evaluated, and we may proceed with the surgery even if the resources are not optimal.

Concerning intraoperative management, we monitor EKG, invasive blood pressure, temperature (two sites), ETCO2, pulse oximetry, Bispectral index, urinary output and blood gases (intermittently). We do not monitor central venous pressure in all cases (due to limited availability of pressure transducers) and the transesophageal echocardiography is not available to be used in the operation room, except in very rare occasions. Our cardiopulmonary bypass machine is relatively simple and some technology, like bubble detectors, real time blood gas analysis and integrated pressure transducers, to monitor the pressure in the bypass circuit, is not present. Extracorporeal membrane oxygenation is the form of circulatory support that is usually available when necessary.

Besides the challenges in the perioperative period, social problems play an important role in the care of patients with CHD. These problems may include poor hygiene, difficult access to medication, poor adherence to treatment and loss to follow-up, and even more complex issues, like abandonment and child abuse. All these issues are somehow related to the general low level of education and poverty.

We have been working together with the multiprofessional team from Seattle Children’s Hospital, USA, via Heartlink, for a few years now, and we have achieved considerable improvement in some areas, like infection prevention. We still have a lot of work to do, but we are confident that soon enough we will reach better quality in the care of our patients.

Editor’s note from Greg Latham, MD
Seattle Children’s Hospital has been fortunate to be part of a 6-9 year cooperative arrangement to assist with growing and improving pediatric cardiac care at Hospital de Messejana in Fortaleza, Cera, Brazil. A team of Seattle Children’s clinicians, including a cardiologist, cardiac surgeon, cardiac intensivist, anesthesiologist, perfusionist, CICU nurse, nutritionist, pharmacist and respiratory therapist, visit yearly to support the cardiac group and maintain ongoing collaborative work. Children’s HeartLink, based in Minneapolis, is the sponsoring organization. In spite of being significantly resource constrained, the cardiac care team in Fortaleza is able to provide remarkable care for children with congenital heart disease.