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Department of Anesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, ChinaPediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
Corresponding author: Jijian Zheng, Department of Anesthesiology, Shanghai Children's Medical Center, Affiliated with Shanghai Jiao Tong University School of Medicine, National Children's Medical Center, 1678 Dongfang Road, Shanghai 200127, China
Department of Anesthesiology, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, ChinaPediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, National Children's Medical Center, 1678 Dongfang Road, Shanghai, China
To describe the current development of Chinese pediatric cardiac anesthesia practices.
Design
Descriptive research
Settings
This study used electronic questionnaires. We searched the official website of the National Health Commission of the People's Republic of China for tertiary maternity and children's hospitals across the country.
Participants
Tertiary maternity and children's hospitals.
Interventions
All representatives of the invited hospitals were asked to report the official statistics of their hospitals whenever possible.
Measurements and Main Results
The survey questions were related to the geographical distribution and caseloads of pediatric cardiac surgical resources, technical capacities, anesthetic regimens, monitoring practices, and qualification requirements of anesthesiologists. One hundred and thirty hospitals were confirmed using the registration information of the National Health Commission of the People's Republic of China, and 108 hospitals agreed to participate in this study. All the enrolled hospitals completed the questionnaires, of which 52 were capable of performing cardiac surgeries and were located in provinces, autonomous regions, and municipalities across the country, except for the Inner Mongolia Autonomous Region, Ningxia Hui Autonomous Region, and Tibet Autonomous Region. We found that the caseload of pediatric cardiac surgeries in most hospitals was relatively small (< 500 cases per year). Hospitals capable of performing high-risk pediatric cardiac surgeries are mainly located in Eastern China. Most hospitals prefer total intravenous anesthesia (TIVA) in cardiac surgeries, and the commonly used anesthetics include propofol, sufentanil, rocuronium, and cis-atracurium. Except for the basic intraoperative monitoring items (including electrocardiography, invasive blood pressure, central venous pressure, pulse oxygen saturation, intake/output volume, and body temperature), bispectral index and near-infrared spectroscopy are relatively commonly used in some hospitals. Postoperative analgesia for children undergoing cardiac surgeries was provided in 38 hospitals, and an intravenous analgesia pump was the most widely used analgesia measure. In addition, the most frequently mentioned qualification requirements for pediatric cardiac anesthesiologists in these hospitals that specialize in cardiac surgeries are further study in domestic hospitals that specialized in cardiac surgeries, and the professional titles of the attending doctors.
Conclusions
Pediatric cardiac medical resources are mainly concentrated in Eastern China, and most hospitals capable of performing high-risk cardiac surgeries are located in the eastern part of the country. We found that pediatric cardiac anesthesia practices varied widely among the hospitals, and the main problem with pediatric cardiac anesthesia in China is that there is no systemic fellowship training curriculum at present; therefore, there is an urgent need to develop a fellowship training curriculum to further improve the quality of Chinese pediatric cardiac anesthesia.
Pediatric cardiac anesthesia is one of the most challenging and difficult subdisciplines in the field of anesthesia because children with congenital heart disease (CHD) are at a much higher risk of inotropic support, cardiac arrest, and higher mortality than relatively healthy children under general anesthesia (1, 2). As a critical contributor to CHD treatment and long-term outcomes, pediatric cardiac anesthesia has experienced dramatic developments in the past decades. In China, the first pediatric cardiac surgery was performed on a child with a patent ductus arteriosus in 1944 (3). Since then, pediatric cardiac anesthesia in China has developed gradually. Today, the most complex and critical CHDs can be treated well in top Chinese pediatric cardiac centers.
Reducing unnecessary clinical variations can effectively improve the quality of medical care (4). However, significant differences in pediatric cardiac anesthesia management may exist in China due to the differences in the economy and medicine of many districts coupled with the lack of high-standard training programs for pediatric cardiac anesthesiologists. To the best of our knowledge, there has been no systematic report on Chinese pediatric cardiac anesthesia practices on the national pediatric cardiac anesthesia registry platform. Therefore, to describe the current pediatric cardiac anesthesia practices and better promote the development of Chinese pediatric cardiac anesthesia, we designed this study to collect information regarding pediatric cardiac anesthesia in China, including the geographical distribution and caseloads of pediatric cardiac surgical resources, technical capacities, anesthetic regimens, monitoring practices and qualification requirements of anesthesiologists.
METHODS
This study was reviewed by our Center's Institutional Review Board, and as it did not involve access to private patient data or alterations in perioperative anesthesia practices, the requirement for ethical approval was waived. According to the registration information provided on the official website of the National Health Commission of the People's Republic of China, we first confirmed 130 tertiary maternity and children's hospitals, then contacted the Department of Anesthesiology of these hospitals and asked each hospital to assign one representative (anesthesiologists experienced in pediatric cardiac anesthesia were invited if hospitals performed pediatric cardiac surgeries) to participate in the study. Later, a WeChat Survey Group was established, and only one representative from each hospital was invited to join this group. An electronic questionnaire was released by the WeChat Survey Group in March 2022, and all representatives were asked to report the official statistics of their hospitals whenever possible. This survey mainly included the geographical distribution and caseload of pediatric cardiac surgeries, the degree of surgical risk that can be performed, anesthetic regimens, intraoperative monitoring and postoperative analgesia practices, and qualification requirements for anesthesiologists.
RESULTS
Of the 130 hospitals invited, 108 agreed to join our study, and the remaining 22 could not be contacted. All the enrolled hospitals completed the questionnaires. Among these hospitals, 52 (48.1%) were capable of performing pediatric cardiac surgeries, and they are located in provinces, autonomous regions, and municipalities across the country except for Inner Mongolia Autonomous Region, Ningxia Hui Autonomous Region, and Tibet Autonomous Region.
Geographical Distribution and Caseloads of Pediatric Cardiac Surgical Resources
Among the 52 hospitals capable of performing pediatric cardiac surgeries, 11 (21.2%) were located in Western China, nine (17.3%) were in Central China, and 32 (61.5%) were found in Eastern China. The geographical distribution of these hospitals is shown in Figure 1. Among the hospitals capable of performing pediatric cardiac surgeries, 37 (71.2%) performed fewer than 500 pediatric cardiac surgeries annually, and 10 (19.2%) performed 500 – 1,000 cases annually. Notably, Jiangxi Provincial Children's Hospital and Guangzhou Women and Children's Medical Center performed 1,000 – 1,500 cases annually. The top three hospitals with the highest annual cases were Children's Hospital of Chongqing Medical University (1,500 – 2,000 cases annually, Western China), Henan Children's Hospital (2,000 – 3,000 cases annually, Central China), and Shanghai Children's Medical Center (3,000 – 4,000 cases annually, Eastern China), respectively. Based on geographical distribution, most hospitals capable of performing pediatric cardiac surgeries are located in Eastern China, and the caseload of pediatric cardiac surgeries in Central and Western China are relatively small compared with those in Eastern China. The details are shown in Table 1.
Figure 1The geographical distribution of hospitals capable of performing pediatric cardiac surgeries. The number of hospitals in each area was indicated with different colour.
Technical Capacities of Pediatric Cardiac Surgeries
Regarding the Risk Adjustment for Congenital Heart Surgery (RACHS-1) scale (5, 6), the degree of cardiac surgical risk that can be performed by tertiary maternity and children's hospitals in China is shown in Figure 2. In this figure, the participants reported anesthesia management for the highest risk degree of cardiac surgeries they could deal with. The results indicated that participants from 13 hospitals could manage anesthesia at the highest risk (RACHS category 6) of cardiac surgeries, and these hospitals were located in 11 provinces and municipalities in China; two (15.4%) were located in Western China, one (7.7%) was in Central China, and 10 (76.9%) were located in Eastern China.
Figure 2Risk degree of cardiac surgeries that can be performed. The highest risk degree of the cardiac surgeries can be performed in each area was indicated with different colour.
Of the 52 hospitals, 18 (34.6%) provided preoperative sedation to children selected for cardiac surgery, and five sedatives, including midazolam, dexmedetomidine, ketamine, chloral hydrate, and sevoflurane, were reported. Midazolam was the primary preoperative sedative used in 10 (55.6%) hospitals (Figure 3) and was administrated orally at a dose of 0.5 mg/kg in 7 hospitals, and intravenously at a dose of 0.1 mg/kg in 3 hospitals. Three (16.7%) hospitals reported that cyanotic CHDs and respiratory distress were contraindications for preoperative sedation. In addition, extreme age (newborns or premature infants), arrhythmia, and airway malformation were considered contraindications in one (5.6%) hospital.
Figure 3Preoperative sedatives used for children selected for cardiac surgeries.
The protocols for anesthesia induction and maintenance varied among the hospitals in this study. The most widely used sedative, analgesic, and muscle relaxant for anesthesia induction were propofol (40.4%), sufentanil (82.7%), and cis-atracurium (44.2%), respectively. In addition, rocuronium was also chosen in 21 (40.4%) hospitals. While for anesthesia maintenance, continuous infusion of propofol (50%), continuous infusion of sufentanil (51.9%), intermittent administration of cis-atracurium (25%), and continuous infusion of rocuronium (25%) were the most common choices. Overall, most of the hospitals in this study preferred total intravenous anesthesia (TIVA) for cardiac anesthesia, and only six (11.5%) hospitals used volatile anesthetics (sevoflurane) for anesthesia maintenance. The details are shown in Table 2.
Table 2Protocols of anesthesia induction and maintenance.
Thirty-eight (73.1%) hospitals provided postoperative analgesia services for children undergoing cardiac surgeries, and the services were provided in five (45.5%) hospitals in Western China, six (66.7%) in Central China, and 27 (84.4%) in Eastern China. Eighteen (47.4%) hospitals stated that multimodal analgesia was used in postoperative analgesia practices, and we found that intravenous analgesia pumps were the most commonly used measure for postoperative analgesia. The details are shown in Table 3. Sufentanil was the primary analgesic used in intravenous analgesia pumps in 26 (78.8%) hospitals, hydromorphone and fentanyl were also used in intravenous analgesia pumps in 2 (6.1%) and 1 (3.0%) hospital, respectively. Four (12.1%) hospitals did not specify analgesia pump regimines.
Table 3The postoperative analgesia methods used for children undergoing cardiac surgeries.
Extreme age (newborns and premature infants) and certain surgical methods (Glenn/Fontan procedure) were considered contraindications for postoperative analgesia in 23 (60.5%) hospitals and one (2.6%) hospital, respectively. Furthermore, 12 hospitals reported no contraindications for postoperative analgesia, and two did not specify any contraindications.
Among the hospitals that provided postoperative analgesia services, eighteen (47.4%) performed nerve block techniques in postoperative analgesia practices. Notably, intercostal nerve block (47.1%), serratus anterior plane block (29.4%), and paravertebral block (23.5%) were the three techniques reported. Ropivacaine was the preferred local anesthetic in 17 (94.4%) hospitals, and bupivacaine was used in 1 (5.6%) hospital. The analgesics and local anesthetics used for postoperative analgesia for children undergoing cardiac surgeries are shown in Table 4.
Table 4The analgesics and local anesthetics used in postoperative analgesia.
Electrocardiography, invasive blood pressure, central venous pressure, pulse oxygen saturation, intake/output volume, and body temperature were the basic monitoring parameters for pediatric cardiac surgeries in all hospitals included in this study. Intraoperative temperature monitoring practices vary among hospitals, as the nasopharynx, esophagus, and rectum are alternative sites of monitoring for temperature measurement. Besides, some hospitals simultaneously monitor the temperature at two sites (Figure 4).
Figure 4Monitoring items used in pediatric cardiac surgeries. Note: TOF: train of four, PiCCO: pulse indicator continuous cardiac output.
The special monitoring items reported in our study included the bispectral index (BIS, 34.6%), near-infrared spectroscopy (NIRS, 19.2%), train of four (TOF, 1.9%), entropy (1.9%), pulse indicator continuous cardiac output (PiCCO, 1.9%), and Narcotrend (1.9%). Most of the special monitoring items are used in hospitals in Eastern China. The details are listed in Table 5.
Table 5Special monitoring items used in pediatric cardiac surgeries.
Intraoperative echocardiography was performed by ultrasound technologists in 38 (73.1%) hospitals, and by cardiothoracic specialists in 3 (5.8%) hospitals. In addition, 3 (5.8%) hospitals did not specify on this issue. Anesthesiologists were responsible of performing intraoperative echocardiography in 8 (15.4%) hospitals.
Qualification requirements for pediatric cardiac anesthesiologists
The qualification requirements (referring to the minimal requirements for anesthesiologists to perform pediatric cardiac anesthesia) reported for pediatric cardiac anesthesiologists in this study mainly included professional titles, working experiences, and further education experiences in hospitals that specialize in cardiac surgeries. The most mentioned qualification requirements for pediatric cardiac anesthesiologists were further studies in domestic hospitals that specialize in cardiac surgeries (44.2%) and professional titles for attending doctors (40.4%). The qualifications requirements for assistants (referring to another anesthesiologist who is less experienced in pediatric cardiac anesthesia and work under direction) were relatively lower than those of anesthesiologists; the most mentioned qualification requirement for assistants was at least 3 years of working experience in pediatric anesthesia (28.8%). In addition, about one-third of the hospitals did not specify the qualifications requirements for assistants. Details are shown in Table 6.
Table 6The qualifications requirements for pediatric cardiac anesthesiologists and assistants.
Qualifications required
Frequency (n=)
Propotion (%)
Anesthesiologists
Professional title
Attending doctor
21
40.4
Associate doctor
14
26.9
Working experiences in pediatric anesthesia
≥ 2 years
1
1.9
≥ 3 years
2
3.8
≥ 5 years
7
13.5
≥ 10 years
12
23.1
≥ 20 years
1
1.9
Working experiences in pediatric cardiac anesthesia
≥ 1 year
1
1.9
≥ 2 years
3
5.8
≥ 3 years
4
7.7
≥ 5 years
10
19.2
≥ 10 years
1
1.9
Education experiences in hospitals that specialized in cardiac surgeries
Further study in domestic hospitals
23
44.2
Further study in hospitals abroad
3
5.8
Training caseload
≥ 30
1
1.9
Not specified
/
3
5.8
Assistants
Professional title
Resident doctor
5
9.6
Attending doctor
14
26.9
Experiences in pediatric anesthesia
≥ 1 year
2
3.8
≥ 3 years
15
28.8
≥ 5 years
8
15.4
≥ 10 years
1
1.9
Experiences in pediatric cardiac anesthesia
≥ 1 year
2
3.8
≥ 2 years
1
1.9
≥ 5 years
1
1.9
Education experiences in hospitals that specialized in cardiac surgeries
The CHD birth prevalence in China has been increasing over the past 40 years (7), and many children require surgical interventions. Su et al. have described the distribution of CHD surgical resources in Northern China and found that high-quality pediatric cardiac surgical resources are mainly concentrated in the eastern region (8). Similar results were concluded nationwide in our study. Besides, our study further reported the anesthesia practices of pediatric cardiac surgeries in China, which will be a beneficial supplement to the panorama of Chinese CHD care.
The caseload of congenital heart surgery in Eastern China is far more than that in Central and Western China, which is possibly due to the unbalanced regional economic development and parents' desire to have their children treated in the best hospitals. In addition, some critically ill children with complex and critical CHD had to be transferred to cardiac centers with top technical capacities, and most of the centers that can perform the highest risk (RACHS category 6) cardiac surgeries are located in Eastern China. Our study further shows that no maternity and children's hospitals in Inner Mongolia, Ningxia, and Tibet can perform pediatric cardiac surgeries. A possible reason for this may be that these areas are relatively underdeveloped and sparsely populated, the pediatric population in these three areas accounts for only 2.3% of the national pediatric population (9). Therefore, children with CHD in these areas may be treated in local general adult hospitals, or receive free aid from other pediatric cardiac centers in China.
Although oral midazolam and intranasal dexmedetomidine are commonly used for preoperative sedation in relatively healthy children, only about one-third of pediatric cardiac centers in China provide preoperative sedation for children with CHD because of concerns about the potential cardiac and respiratory depression caused by sedatives. From our experience, an oral dose of 0.5 mg/kg midazolam is relatively safe for children with CHD, and respiratory depression is rarely observed; however, an increasing dose of midazolam may be associated with an increased incidence of respiratory depression, or even obstruction (10, 11). In contrast, dexmedetomidine has little effect on respiration and pulmonary artery pressure, even in children with pulmonary hypertension prior to sedation (12, 13). Therefore, dexmedetomidine might be a better choice than midazolam for preoperative sedation in children with pulmonary hypertension. However, special attention should be paid to children who rely on heart rate and systemic vascular resistance to maintain cardiac output.
Since fentanyl was first introduced into clinical anesthesia for cardiac surgery in 1981, the "high-dose" opiate-based TIVA technique has been widely used in cardiac surgery centers due to its high hemodynamic stability. However, since volatile anesthetics have shown a protective effect on important organs, such as the heart, lung, and kidneys (14, 15, 16), volatile anesthetics have been another important choice for anesthesia maintenance of cardiac surgeries. The impact of anesthesia techniques on the outcomes of patients undergoing cardiac surgeries is an attractive topic. A recent study indicated that anesthesia techniques did not influence the outcomes in adults undergoing cardiac surgeries (17). However, the answer to this question can be different in the pediatric population, especially in young infants. Current evidence suggests that cardiac surgeries in early infancy are associated with delayed cognitive and motor development (18), and a large dose of volatile anesthetics can be a risk factor for adverse neurodevelopmental outcomes in neonates undergoing cardiac surgeries (19).
In addition to the traditional monitoring parameters used during cardiac anesthesia, an increasing number of cardiac centers use BIS and NIRS in pediatric cardiac surgeries in China since they are effective supplements for intraoperative monitoring of cardiac anesthesia. BIS is widely used to reflect anesthesia depth, while NIRS is used to reflect the adequacy of cerebral oxygen delivery and demand, especially in cases of arch repair with selective antegrade perfusion (20,21). Although recent studies have indicated that NIRS cerebral monitoring shows no significant benefits in improving neurological outcomes in patients undergoing cardiac surgeries (22,23), it remains an indicator of organ perfusion during cardiopulmonary bypass. Notably, BIS and NIRS were the most commonly used monitoring methods in addition to the basic monitoring items in pediatric cardiac centers in our study, but they are not yet universal in China. In addition, BIS and NIRS are used more frequently in Eastern China than in Central and Western China, which reflects a gap in the updating of equipment and knowledge of intraoperative monitoring in pediatric cardiac surgeries between the different areas.
Analgesia is an important element of postoperative management in children undergoing cardiac surgeries, and insufficient analgesia can result in delayed recovery and cardiopulmonary instability (24). Unfortunately, in this study, postoperative analgesia services were unavailable in 14 hospitals. Although the analgesic effect of intraoperative sufentanil can be maintained for several hours after surgery, this issue still remains to be addressed. It should also be noted that extreme age (newborns and premature infants) was considered a contraindication for postoperative analgesia in over half of the hospitals in our study, possibly due to the concern of slow drug clearance and opioids accumulation in this age group (25,26). In light of this, an individualized opioid-dexmedetomidine analgesia strategy can be considered for neonates to lower the dosage of opioids and achieve sufficient analgesic effects (27).
The ultrasound-guided nerve block technique has been proven to be a simple, safe, and effective analgesia method for children undergoing cardiac surgeries (28,29), but we observed that only 17 (32.7%) pediatric cardiac centers regularly use this analgesia technique, even though ultrasound equipment is available in 47 (90.4%) centers, which might be due to the concern of increased bleeding risk during cardiac surgery.
The qualification requirements for pediatric cardiac anesthesiologists in Chinese tertiary maternity and children's hospitals vary widely. To the best of our knowledge, there is presently no systemic fellowship training curriculum for pediatric cardiac anesthesiologists in China, as against the qualifications requirements of pediatric cardiac anesthesiologists in the United States and Europe, where at least 100 cases are required to complete a training curriculum (30,31). One of the most mentioned qualification requirements in our study is the professional title, and only one hospital ambiguously stated that at least 30 cases were required to become pediatric cardiac anesthesiologists. In reality, to become a pediatric cardiac anesthesiologist, one must first become a qualified attending general anesthesiologist and then go to advanced pediatric cardiac centers for further study of pediatric cardiac anesthesia for at least half a year. Therefore, to further improve the quality of pediatric cardiac anesthesia in different regions of China, it is necessary to develop a high-standard pediatric anesthesia fellowship training program.
Limitation
Although we invited most of the tertiary maternity and children's hospitals registered with the official website of the National Health Commission of the People's Republic of China, 22 hospitals were still excluded from the study. Besides, some data may have been overlooked because the respondents in this study were restricted to tertiary maternity and children's hospitals, as pediatric cardiac surgeries may also be performed in general hospitals in China. Furthermore, due to the lack of official statistical data, some important information regarding prognosis assessment, such as the incidence of major complications and mortality, were not provided in this study. Thus, we cannot compare the outcomes of CHD children in China with those in institutions utilizing formal pediatric cardiac anesthesia training programs. It should be acknowledged that the data collected in this study is not very comprehensive; however, considering that all of the major and representative tertiary maternity and children's hospitals in each province, municipality, and autonomous region were included in this study, we still believe that our study has shed light on the current pediatric anesthesia practices in China.
In conclusion, our study showed pediatric cardiac surgical services are available in most areas of China. We found that an imbalance in the geographical distribution of pediatric cardiac medical resources still exists, and the most remarkable problem is that there is currently no systemic fellowship training program. We hope that our work will attract more attention from Chinese anesthesiologists, contribute to the development of a national fellowship training program, and further improve the quality of pediatric cardiac anesthesia care.
Approval Statement
This study was reviewed by the Institutional Review Board of Shanghai Children's Medical Center, and as it did not involve access to private patient data or alterations in pediatric perioperative practices, the requirement for ethical approval was waived.
Funding
None.
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