title: Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events.
abstract: BACKGROUND
  Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery.
  
  
  OBJECTIVE
  To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery.
  
  
  METHODS
  This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded.
  
  
  RESULTS
  During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h.
  
  
  CONCLUSIONS
  We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic.
authors.affiliation: Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA.
authors.forename: Morgan L
authors.initials: ML
authors.lastname: Brown
authors.affiliation: Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: DiNardo
authors.affiliation: Division of Cardiac Anesthesia, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA.
authors.forename: Kirsten C
authors.initials: KC
authors.lastname: Odegard
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000009:adverse effects*; D015897:Comorbidity; D005260:Female; D018729:Fontan Procedure; D006330:Heart Defects, Congenital / Q000453:epidemiology*; D006352:Heart Ventricles / Q000002:abnormalities*; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*
keywords: Norwood procedures; anesthesia; congenital; heart defects; intraoperative complications; operative; postoperative complications; surgical procedure