• Cincinnati Children's Hospital Medical Center. Evidence based care guideline for anesthesia, analgesia and sedation following arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jan 10. 8 p. [16 references]

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for anesthesia, analgesia and sedation following arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 22. 8 p.

Once the guideline has been in place for four years, the development team reconvenes to explore the continued validity of the guideline. This phase can be initiated at any point that evidence indicates a critical change is needed.

Each recommendation is followed by evidence grades identifying the type of supporting evidence. Definitions of the evidence grades are presented at the end of the "Major Recommendations" field.

Clinical Assessments

1. It is recommended that hemodynamic stability be maintained as indicated by mean arterial pressure >45, left atrial pressure <15, and urine output >1cc/kg/hr. Physical exam should indicate adequate perfusion.

   Note 1: Continuous monitoring of electrocardiogram (ECG) and arterial blood pressure via an arterial line is recommended (Local Expert Consensus [E]).

   Note 2: Continuous monitoring of left atrial pressure with a transthoracic catheter is recommended (Local Expert Consensus [E]).

2. It is recommended that adequate pain relief is provided as indicated by behavioral assessment and the absence of otherwise unexplained tachycardia or hypertension.
3. It is recommended that patient comfort and sedation be maintained as indicated by behavioral assessment. The patient should not be at risk for inadvertent self-removal of lines and/or tubes.

Treatment Recommendations

4. It is recommended that a fentanyl infusion at 10 micrograms/kg/hr be started on all post-operative arterial switch patients and maintained for at least 6 hours. The infusion should be discontinued if the patient has had no signs or symptoms of low cardiac output (mean arterial pressure <45, urine output <1 cc/kg/hr, persistent base deficit >-4 despite correction with sodium bicarbonate [NaHCO₃] or increase in lactate level >0.5 mg/dl/hr) and is therefore considered a good candidate for extubation in the next 24 hours.

   Note 1: A continuous infusion of high-dose fentanyl is maintained to blunt the physiologic stress response that occurs as a consequence of cardiac surgery (Anand, Hansen, & Hickey, 1990 [D]; Anand & Hickey, 1992 [B]). Because cardiac output decreases for at least the first 6 hours following cardiopulmonary bypass, it is recommended that the infusion be continued for at least this length of time (Wernovsky et al., 1995 [A]).

   Note 2: Because of the redistribution of fentanyl into lipid tissue, long-term infusion may result in prolongation of side effects such as apnea well beyond termination of the infusion (Cincinnati Children's Hospital Medical Center Formulary, 2006)[X]. Therefore, once pain management, rather than hemodynamic stability, becomes the primary reason for narcotic use, it is desirable to use bolus dosing of a less lipophilic agent such as morphine and to discontinue the fentanyl infusion (Local Expert Consensus [E]).

   Note 3: Ongoing metabolic acidosis caused by the continued production of lactic acid has been associated with a poor outcome following cardiac surgery in infants and children. (Charpie et al., 2000 [C]; Munoz et al., 2000 [C]).

5. It is recommended that midazolam (0.1 mg/kg/dose every 1 to 2 hours) or lorazepam (0.1 mg/kg/dose every 6 to 8 hours) be given concurrently with the fentanyl infusion to ensure adequate sedation in addition to anesthesia/analgesia.

   Note: Because of the variability in neonatal response to fentanyl and because of rapid development of tolerance to its sedative effects (in contrast to respiratory depressant effects), additional use of benzodiazepines is often necessary to maintain adequate sedation (Arnold et al., 1991 [C]).

6. It is recommended that adequate analgesia and sedation be provided using as needed doses of morphine (0.1 mg/kg/dose) and midazolam (0.1 mg/kg/dose) once the fentanyl infusion has been discontinued.

   Note: The longer half-life of morphine makes it a better choice for intermittent dosing than fentanyl. The histamine release associated with morphine should be well tolerated hemodynamically by patients who are otherwise stable 6 hours after cardiopulmonary bypass (Saarenmaa et al., 1999 [A]; Saarenmaa, Neuvonen, & Fellman, 2000 [C]; Santeiro et al., 1997 [C]; Hamon et al., 1996 [C]; Katz & Kelly, 1993 [C]; Arnold et al., 1991 [C]; Murat et al., 1988 [C]).

Definitions:

Evidence Based Grading Scale

M: Meta-analysis or systematic review
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
S: Review article
O: Other evidence
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

None provided

The type of evidence is identified and classified for each recommendation (see "Major Recommendations") using the following scheme:

M: Meta-analysis or systematic review
A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
S: Review article
O: Other evidence
E: Expert opinion or consensus
F: Basic laboratory research
L: Legal requirement
Q: Decision analysis
X: No evidence

• Cincinnati Children's Hospital Medical Center. Evidence based care guideline for anesthesia, analgesia and sedation following arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2006 Jan 10. 8 p. [16 references]

Not applicable: The guideline was not adapted from another source.

2001 Jan 22 (revised 2006 Jan 1)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Cincinnati Children's Hospital Medical Center

Cardiac Guideline Development Team 2006

Cincinnati Children's Hospital Medical Center Physicians: Peter Manning , MD, Cardiac Surgery; Catherine Dent, MD, Cardiac Intensive Care; William Border, MD, Cardiology; James Spaeth MD, Anesthesia; Michael Alice Moga, MD, Cardiology/Fellow

Patient Services: Karen Uzark, PhD, CPNP, Cardiology; Susan Ryckman, MS, CPNP, Cardiac Services; Betsy Adler, MS, PNP, Cardiac Surgery; Melissa Magness, RN, Cardiac ICU; Tammy Lingsch, RN, A6 Central; Cynthia Wedekind, Pharm D, Clinical Pharmacy; Jenni Raake, RRT, Respiratory Care; Shawna Kirkendall, RN, Manager, A 6 Central

Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH; Danette Stanko, MA, MPH, Epidemiologist; Kate Rich, Lead Decision Support Analyst; Carol Frese, RN, Medical Reviewer; Eduardo Mendez, RN, MPH, Dir. Evidence-Based Care; Edward Donovan, MD, Medical Director, Clinical Effectiveness

This guideline was developed without external funding.

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for anesthesia, analgesia and sedation following arterial switch operation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2001 Jan 22. 8 p.

Once the guideline has been in place for four years, the development team reconvenes to explore the continued validity of the guideline. This phase can be initiated at any point that evidence indicates a critical change is needed.

None available

This NGC summary was completed by ECRI on March 11, 2004. This NGC summary was updated by ECRI on November 29, 2006. The updated information was verified by the guideline developer on December 19, 2006.