Table of Contents  
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 238-241

Factors affecting anesthetic complications in children undergoing congenital cardiac catheterization

Department of Anesthesia; Department of Cardiology, Ain Shams University Hospital, Cairo; Magdi Yacoub Heart Foundation, Aswan Heart Center, Aswan, Egypt

Date of Submission02-Dec-2013
Date of Acceptance01-Jan-2014
Date of Web Publication31-May-2014

Correspondence Address:
Ayman I. Tharwat
76 Atef Elsadatst, 1st district, elshrook city, P.O. Box 111, Cairo 11837
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.133449

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Anesthetic complications are among the most common adverse effects in congenital cardiac catheterization. Although the presence of an expert pediatric anesthetist will markedly reduce these complications, other factors may contribute toward their development.
To determine the factors associated with the development of anesthetic complications in children undergoing congenital cardiac catheterization.
Materials and Methods
We carried out a prospective study of 71 patients who underwent cardiac catheterization over a period of 6 months and analyzed the intracatheterization and postcatheterization anesthetic complications.
The most common anesthetic complication was delayed recovery (11.3%). Other less common adverse events included postoperative vomiting (2.8%), sinus tachycardia (2.8%), postoperative agitation (1.4%), intraoperative arousal (1.4%), and intraoperative apnea (1.4%). Patients who had no anesthetic adverse events were significantly older and had higher body weight compared with those who had one or more anesthetic problems. In addition, patients who had anesthetic adverse events had significantly longer procedure time compared with those who had no anesthetic complications.
Factors that can contribute toward anesthetic adverse events in children undergoing cardiac catheterization include a longer procedure time, longer duration of anesthesia, and younger age.

Keywords: Anesthetic complications, catheterization, pediatric cardiac intervention

How to cite this article:
Tharwat AI, Roushdy AM. Factors affecting anesthetic complications in children undergoing congenital cardiac catheterization. Ain-Shams J Anaesthesiol 2014;7:238-41

How to cite this URL:
Tharwat AI, Roushdy AM. Factors affecting anesthetic complications in children undergoing congenital cardiac catheterization. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Nov 29];7:238-41. Available from:

  Introduction Top

Pediatric cardiac catheterization procedures have replaced many surgical procedures recently, with increasing number of congenital heart diseases being treated efficiently using these procedures. This field has witnessed a dramatic increase in the number and type of procedures performed over the last decade [1].

Pediatric cardiac interventions are complex procedures that are usually associated with hemodynamic instabilities for variable periods of time during the procedure. Most of these procedures require complete immobility of the patients for safe and successful outcome; thus, deep sedation or general anesthesia (GA) is essential and may result in considerable risk to these patients as children represent one of the highest risk groups when subjected to sedation/anesthesia because of their lowest error tolerance [1],[2].

Our hospital is a tertiary center for congenital cardiac disease. The current workload for congenital cardiac catheterizations in our center ranges from 300 to 500 catheterizations per year. We sought to determine the frequency and severity of anesthetic complications among our patients and identify patient and procedural characteristics associated with these complications in a prospective study carried out over a 6-month duration.

  Materials and Methods Top

Seventy-one patients undergoing percutaneous cardiac interventions were recruited for this study; an informed consent was signed by the parents. Exclusion criteria included age older than 18 years or less than 2 months, acute pulmonary infection, history of obstructive sleep apnea, increased intracranial or intraocular pressure, parental refusal, morbid obesity, and poor general condition because of noncardiac congenital anomalies.

All procedures were performed by an experienced interventional pediatric cardiologist with a minimum of 3 years' experience in performing diagnostic and interventional procedures. Anesthesia was managed by a senior anesthetist with the assistance of a qualified anesthesia nurse.

Intravenous cannulation was performed in the preparatory room in the presence of one of the parents; atropine 0.01 mg/kg, followed by preoperative sedation in the form of ketamine 0.5-1 mg/kg and midazolam hydrochloride 0.05 mg/kg is administered for children older than 3 years of age (maximum 3 mg/kg). In case of difficult cannulation (failed three consecutive trials), ketamine 3-6 mg/kg is administered intramuscularly mixed with atropine 0.05 mg/kg with a 22 G needle in the deltoid muscle, followed by cannulation after the patient is calm enough.

After transfer to the catheter laboratory, a slow intravenous injection of propofol 2 mg/kg, fentanyl 1-2 μg/kg, and atracurium 0.5 mg/kg for induction of GA was administered, followed by intubation and mechanical ventilation; sevoflurane 2.5% was used for maintenance of GA. Atropine was administered before ketamine to minimize salivary and tracheobronchial tree secretions, whereas midazolam hydrochloride was administered concomitantly with ketamine in children older than 3 years to reduce the risk of adverse psychological disturbances that may result from the administration of ketamine, which include delusions, hallucinations, agitation, and emergent delirium.

Initiation of the procedure was permitted only after minimal response to painful stimuli (i.e. nail-bed pressure). Duration of GA was defined as the time (in minutes) from administration of GA till recovery. Duration of procedure was defined as time (in minutes) from initiation of the interventional procedure (including sterile preparation of patient) to termination of the procedure (i.e. end of painful stimuli) [1].

Recovery time was defined as the interval (in minutes) from discontinuation of inhalational anesthesia to the time the patient fulfilled the established criteria for discharge to the recovery room [1],[2]. Delayed recovery was defined as failure to fulfill the criteria for discharge to the recovery room or failure to extubate 10 min after discontinuation of inhalational anesthesia [3],[4]. Prolonged apnea was defined as a greater than 5% decrease in oxygen saturation from the baseline level in a patient who was unresponsive to oxygen delivered through a face mask at 6 l/min [5].

Need for resuscitation was defined as a decrease in respiratory rate and oxygen saturation that necessitated either assisted positive pressure ventilation, cardiopulmonary resuscitation, or the administration of resuscitation medications.

Gastrointestinal problems were specified as vomiting, aspiration, or diarrhea. Allergic reactions were defined as unexplained rashes or clinical symptoms [5]. Anesthesia duration, procedure durations, recovery times, and adverse events during the procedure and in the recovery room were recorded by the anesthesia nurse.

Statistical analysis

Data were coded and analyzed using the statistical package for social sciences program, version 18.0. Qualitative data were presented using frequency and its related percentage, whereas quantitative data were presented using the mean and SD. Changes in continuous variables were evaluated using the paired t-test, whereas changes in qualitative variables were evaluated using the c2 -test. A P value less than 0.05 was considered as the level of significance.

  Results Top

Seventy-seven patients were initially considered eligible for enrollment in the study; of these, six patients were excluded because of the presence of comorbidities that could increase the risk of cardiac catheterization. The remaining 71 patients who were referred for elective cardiac catheterization for the possibility of a percutaneous cardiac intervention over a 6-month period were confirmed to be eligible for the study. Of these patients, 8 (11.3%) underwent diagnostic cardiac catheterization and 63 (88.7%) underwent interventional procedures.

All patients included in the study were American society of anesthesiologist class II. The age of the study group ranged from 2 months to 18 years, with a mean age of 3.77 ± 4.442 years, and the body weight ranged from 5 to 62 kg, with a mean of 16.02 ± 12.04 kg. The study group included 36 males (50.7%) and 35 females (49.3%). Patients' demographic data are listed in [Table 1].
Table 1: Demographic data of the study group

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The patients included in the study underwent a wide range of percutaneous cardiac intervention procedures. These procedures included balloon pulmonary valvuloplasty, atrial septal defect device closure, patent ductusarteriosus closure, balloon mitral valvuloplasty, balloon aortic valvuloplasty, and ventricular septal defect device closure. Of note, eight patients were scheduled initially for a percutaneous intervention and after establishing the vascular access and carrying out the necessary invasive hemodynamic studies or anatomical assessment of the atrial septal defect under GA, were deemed unsuitable for further percutaneous intervention.

Sixteen patients (22.5%) experienced one or more anesthesia-related complications. The most common anesthetic complication was delayed recovery (11.3%). Other less common adverse events included postoperative vomiting (2.8%), sinus tachycardia (2.8%), postoperative agitation (1.4%), intraoperative arousal (1.4%), and intraoperative apnea (1.4%) [Table 2].
Table 2: Anesthesia-related complications divided by type

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The study group was subdivided into two subgroups according to whether or not patients experienced any anesthesia-related complications. There was no significant difference between the two groups in the type of procedure performed. There was no significant difference between the two subgroups in the usage of transesophogeal echocardiogram [Table 3] and [Table 4].
Table 3: Comparison between the two groups of the study in procedure type

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Table 4: Comparison between the two groups of the study in the usage of TEE

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Comparison of different relevant quantitative variables between the two subgroups using the paired t-test showed a significant difference between the two groups in patient age, procedure duration, and duration of anesthesia. Patients in group 2 who experienced anesthesia-related complications had significantly longer catheterization duration, and longer anesthesia duration and recovery time (P < 0.0001). Also, the patients in group 2 were considerably younger than the patients in group 1 (1.9 ± 4.3 vs. 4.3 ± 4.3 years) [Table 5].
Table 5: Comparison of the different quantitative variables between the two subgroups of the study

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  Discussion Top

In this single-center prospective study of 71 pediatric patients who underwent percutaneous cardiac interventions, patients who experienced anesthesia-related complications had significantly longer procedure and anesthesia duration than those who did not experience these complications. Also, these patients were considerably younger compared with patients who did not experience anesthesia-related complications.

Our results were in agreement with those of Ruwan et al. [6], who studied 607 pediatric patients receiving anesthesia for imaging procedures; they concluded that the duration of anesthesia and the presence of preoperative respiratory problems resulted in more anesthesia-related complications.

However, Mario et al. [7] studied the perioperative complications in 156 pediatric patients with pulmonary hypertension undergoing cardiac and noncardiac catheterization; they concluded that complications were not significantly associated with age, type of anesthesia, or airway management.

Athina et al. [8] carried out a multivariate regression analysis on 8707 pediatric patients undergoing different surgical procedures; they concluded that higher American society of anesthesiologist status or younger age led to higher incidence of intraoperative adverse events.

Davinia et al. [9] concluded that adverse events occur more commonly during cardiac catheterization than during pediatric anesthesia in general. Cases with the highest risk are those younger than 1 year of age. Najat et al. [10] studied a sample that included 90 children attending GA for dental treatment; age, sex, admission type of the patients, and GA duration were the factors that showed a significant relationship with postoperative complaints.

Study limitations and recommendations

This study was carried out using the expertise of a single experienced pediatric anesthetist with considerable experience in pediatric anesthesia, especially in cardiac patients. Whether or not anesthesia-related complications may be affected by the level of experience of the anesthetist in charge is an issue that has yet to be addressed. Also, the anesthesia protocols used in the pediatric patients in the catheterization laboratory vary from one institution to another and whether the anesthesia protocol itself can affect the development of complications is another issue that may be addressed in future studies.

Larger numbers of patients over a longer period of time should be included in future studies to be able to produce a multivariate analysis model that could suggest the most important independent factors affecting anesthesia-related complications in children undergoing interventional cardiac procedures.

  Conclusion Top

Factors that can contribute toward anesthetic adverse events in children undergoing cardiac catheterization include longer procedure time, longer duration of anesthesia, and younger age.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

1.American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89:1110-1115.  Back to cited text no. 1
2. Bennett JA, Bullimore JA. The use of ketamine hydrochloride anaesthesia for radiotherapy in young children. Br J Anaesth 1973; 45:197-201.  Back to cited text no. 2
3. Marx CM, Stein J, Tyler MK, Nieder ML, Shurin SB, Blumer JL. Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients. J Clin Oncol 1997; 15:94-102.  Back to cited text no. 3
4. White PF. Ketamine update: its clinical uses in anesthesia. Semin Anesth 1998; 7:113-126.  Back to cited text no. 4
5. Mason KP, Michna E, DiNardo JA, Zurakowski D, Karian VE, Connor L, Burrows PE. Evolution of a protocol for ketamine induced sedation as an alternative to general anesthesia for interventional radiologic procedures in pediatric patient. Radiology 2002; 225:457-465.   Back to cited text no. 5
6. Kiringoda R, Thurm AE, Hirschtritt ME, et al. Risks of propofol sedation/anesthesia for imaging studies in pediatric research: eight years of experience in a clinical research center. Arch Pediatr Adolesc Med 2010; 164:554-560.  Back to cited text no. 6
7. Carmosino MJ, Friesen RH, Doran A, et al. Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization. Anesth Analg 2007; 104:521-527.  Back to cited text no. 7
8. Kakavouli A, Li G, Carson MP, et al. Intraoperative reported adverse events in children. Pediatr Anesth 2009; 19:732-739.  Back to cited text no. 8
9. Benette D, Marcus R, Stoks M. Incidents and complications during pediatric cardiac catheterizations. Pediatr Anesth 2005; 15:1083-1088.  Back to cited text no. 9
10.1 FarsiN, Ba′akdah R, Boker A, et al. Postoperative complications of pediatric dental general anesthesia procedure provided in Jeddah hospitals, Saudi Arabia. BMC Oral Health 2009; 9:6.  Back to cited text no. 10


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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