Standardized management improves outcomes after the Norwood procedure.
BACKGROUND
In the past decade, many advances in the care of patients undergoing the Norwood procedure (NP) have been reported, but management remains nonstandardized at many institutions. We studied the impact of a standardized management protocol for neonates undergoing NP.


METHODS
Care of NP patients has been protocol-driven at our institution since 2005, with routine use of regional low flow perfusion; near infrared spectroscopy; phenoxybenzamine with cardiopulmonary bypass; delayed sternal closure; peritoneal drainage; gastrostomy tubes; postoperative vocal cord assessment; and a home surveillance program of daily weight and oxygen saturation measurement. Patients undergoing NP from 2001 to 2004 (n = 40, group 1), in whom these interventions were only selectively employed, were retrospectively compared with those receiving standardized management from 2005 to 2007 (n = 40, group 2), with endpoints of survival in-hospital and to stage 2 palliation (S2P). Effect of protocol elements on outcome was evaluated by univariate and multivariate analyses.


RESULTS
Hospital survival (95% vs. 70%, P= .003) and survival to S2P (85% vs. 58%, P= .006) was better in group 2. By univariate analysis, regional low flow perfusion, gastrostomy usage, and near infrared spectroscopy were associated with improved hospital and survival to S2P. In multivariable analysis, gastrostomy usage was associated with improved hospital survival (P= .027) and survival to S2P (P= .049), while our home surveillance program was a predictor of survival to S2P (P= .016).


CONCLUSIONS
Protocol-driven management of NP patients was associated with better hospital survival and survival to S2P. Among protocol elements, gastrostomy usage was linked to both improved hospital survival and survival to S2P. Home surveillance was associated with increased survival to S2P.
Srinivasan
Chandra
C
Division of Pediatric Cardiology, Arkansas Children's Hospital, Little Rock, Arkansas 72202, USA. srinivasanchandra@uams.edu
Sachdeva
Ritu
R
Morrow
W Robert
WR
Gossett
Jeff
J
Chipman
Carl W
CW
Imamura
Michiaki
M
Jaquiss
Robert D B
RD
D000317:Adrenergic alpha-Antagonists / Q000627:therapeutic use; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards*; D002315:Cardiopulmonary Bypass / Q000592:standards; D002675:Child, Preschool; D002985:Clinical Protocols / Q000592:standards*; D004322:Drainage / Q000592:standards; D005260:Female; D005774:Gastrostomy / Q000592:standards; D006699:Home Care Services / Q000592:standards; D017052:Hospital Mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000401:mortality / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D010166:Palliative Care / Q000592:standards; D010348:Patient Care Team / Q000592:standards*; D010477:Perfusion / Q000592:standards; D010643:Phenoxybenzamine / Q000627:therapeutic use; D016730:Program Development; D015397:Program Evaluation; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D019265:Spectroscopy, Near-Infrared / Q000592:standards; D013249:Sternum / Q000601:surgery; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
D000317:Adrenergic alpha-Antagonists; D010643:Phenoxybenzamine