Pain Management After Comprehensive Stage 2 Repair for Hypoplastic Left Heart Syndrome

Aymen N. Naguib, Elisabeth Dewhirst, Peter D. Winch, Janet Simsic, Mark Galantowicz, Joseph D. Tobias

Achieving optimal pain control for children after complex cardiac surgery can be challenging. Recently, the hybrid approach to palliation of hypoplastic left heart syndrome (HLHS) was introduced as an alternative to the classic Norwood procedure. The second stage of the hybrid approach is a complex procedure known as comprehensive stage 2 (CS2). The authors have noted that pain control after the CS2 procedure is particularly difficult to manage. This report presents a review of the authors' pain management strategy in this clinical scenario and evaluates its efficacy. The medical records of patients who underwent CS2 repair of the hybrid procedure for HLHS between June 2008 and August 2011 were retrospectively reviewed. As a comparative group with a similar physiology, patients undergoing an isolated Glenn procedure also were reviewed. In addition to demographic data, the intraoperative use of narcotics and other adjunct medications for analgesia and sedation was recorded. Postoperatively, the mode of analgesia, the total opioid administered during the first 48 h postoperatively, and the nursing-assessed patient pain scores were recorded. Any adverse drug effect or need to adjust the analgesic regimen was recorded, as well as the timing of tracheal extubation. During the study period, 36 patients ranging in age from 4 to 14 months underwent the CS2 procedure, and 21 patients underwent a Glenn procedure. After CS2 repair, fentanyl was the opioid initially prescribed for all but 2 of the 21 patients managed with the nurse-controlled analgesia (NCA) delivery method and 15 patients managed with continuous infusion. After the Glenn shunt, all patients were prescribed NCA, with 20 patients receiving fentanyl and 1 patient receiving hydromorphone. The use of intraoperative dexmedetomidine caused a decrease in the total narcotic requirements, although this did not reach a statistical significance for either the extubated or intubated patients after CS2. The extubated patients who underwent the Glenn procedure received a smaller total equivalent dose of fentanyl during the first 24 h (29.02 ± 10.6 μg/kg) than did the extubated patients after the CS2 procedure, who received an average of 37.92 ± 8.5 μg/kg (P = 0.02). During the second 24 h, the extubated Glenn patients continued to receive less fentanyl, at an average dose of 7.02 ± 11.5 μg/kg compared with 27.7 ± 23.1 μg/kg for the CS2 patients (P = 0.02). The extubated patients who underwent the Glenn procedure required less NCA time (33.68 ± 17.7) than the CS2 patients (57.9 ± 31.8 h) (P = 0.04). Dexmedetomidine use with the CS2 patients resulted in a trend toward lowering of the total fentanyl dose, but this did not reach statistical significance. The intubated patients who received dexmedetomidine after the CS2 procedure had less NCA time (61.7 ± 39.2 vs. 128.1 ± 100 h; P = 0.02). After the CS2 procedure for palliation of HLHS, patients experience a complex pain profile that differs from the pain associated with the traditional Glenn procedure. This group of patients generally can be managed with fentanyl NCA. Achieving a balance between a proper level of analgesia and sedation in the setting of early tracheal extubation to optimize postoperative physiology can be challenging. The preliminary data suggest that improvements in pain management should be investigated given that more than 30 % of the pain scores in the CS2 group were in the moderate to severe range compared with 18 % after the Glenn procedure.