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Gastrointestinal complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease

Part of: The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD)

Published online by Cambridge University Press:  01 December 2008

Nancy S. Ghanayem ,
Joseph A. Dearani ,
Karl F. Welke ,
Marie J. Béland ,
Irving Shen  and
Tjark Ebels
Nancy S. Ghanayem*
Affiliation:
Department of Pediatrics, Division of Critical Care, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
Joseph A. Dearani
Affiliation:
Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
Karl F. Welke
Affiliation:
Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon, United States of America
Marie J. Béland
Affiliation:
Division of Paediatric Cardiology, The Montreal Children’s Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
Irving Shen
Affiliation:
Inova Fairfax Hospital for Children, Falls Church, Virginia, United States of America
Tjark Ebels
Affiliation:
Groningen University Medical Centre, Groningen, The Netherlands
*
Correspondence to: Nancy Ghanayem MD, Division of Critical Care, Children’s Hospital of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, Wisconsin 53201, United States of America. Tel: (414) 266 3360; Fax: (414) 266 3563; E-mail: nancyg@mcw.edu
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Abstract

A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with, suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval.

The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrinal systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the gastrointestinal system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases.

Although serious gastrointestinal complications are relatively uncommon after congenital cardiac surgery, accurate estimates of the incidences of these complications are limited, in part due to lack of standardized reporting and the absence of universal nomenclature that defines organ-specific complications. The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease has prepared and defined a list of gastrointestinal complications that may be temporally associated with congenital cardiac surgery. Clinicians caring for patients with congenital cardiac disease will be able to use this list for databases, initiatives to improve quality, reporting of complications, and comparing strategies of treatment.

Keywords

Congenital heart diseasequality improvementpatient safetyoutcomesregistryoperative morbiditypaediatricsurgerycongenital abnormalitiescardiac surgical proceduresheartgastrointestinal tract
Type
Original Article
Information
Cardiology in the Young , Volume 18 , Issue S2: Databases and the assessment of complications associated with the treatment of patients with congenital cardiac disease , December 2008 , pp. 240 - 244
Copyright
Copyright © Cambridge University Press 2008

Historical background

Serious abdominal complications after cardiac surgery are relatively uncommon and have been predominantly identified in adults. The average incidence of abdominal complications in adults is low, approximately 1.2%, with a range of 0.2 to 5.5%, but when incurred these complications are associated with a substantial increased risk of morbidity and mortality.Reference Hessel1, Reference D’Ancona, Baillot and Poirier2 Similar gastrointestinal complications are seen in association with congenital cardiac surgery, but are less frequently reported in the literature.

Limitations in estimating the incidence and burden of organ-specific complications in congenital cardiac surgery are confounded by the absence of several elements:

  • • uniformly applied standardized reporting

  • • consistent reporting of outcomes beyond commonly used global performance measures such as mortality and length of stay in the hospital

  • • accurate identification of organ-specific morbidity including the temporal association with surgery, and

  • • universal nomenclature which defines specific gastrointestinal complications.

Further difficulty may arise when attributing causality, particularly in the sick infant with congenital anomalies.

Standardized nomenclature for gastrointestinal complications is limited, and potentially more challenging to define when temporally relating these complications to congenital cardiac surgery. Despite the differing nature of cardiac disease in adults compared to children, as well as different pre-existing morbidities, and social behaviours often unique to adults, clinicians and societal organizations have continued to extrapolate adult-focused diagnostic criteria for organ-specific complications, and extend these definitions to infants and children. Currently, consensus definitions for specific gastrointestinal complications following congenital and pediatric cardiac surgery are sparse. A working group representing the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease was convened to better identify and define organ-based complications. The objective of this manuscript is to provide the consensus-derived definitions of gastrointestinal complications associated with congenital cardiac surgery.

Consensus definitions

In Part 4 of this Supplement, within each organ system, complications are presented and defined in alphabetical order. The process for creating this list of complications began in 1998 with initiation of the International Congenital Heart Surgery Nomenclature and Database Project of The Society of Thoracic Surgeons and The European Association for Cardiothoracic Surgery.Reference Mavroudis and Jacobs3 In April of 2000, common database standards for congenital cardiac surgery were published and incorporated into the databases of The Society of Thoracic Surgeons and The European Association for Cardiothoracic Surgery. In addition, the Congenital Heart Surgery Databases of The Society of Thoracic Surgeons and The European Association for Cardiothoracic Surgery have used a common Complications Short List since 2000.Reference Franklin, Jacobs and Tchervenkov4 Starting with the Complications Short List of The Society of Thoracic Surgeons and The European Association for Cardiothoracic Surgery, a draft of a more complete Complications Long List was created. This effort led to the formation of the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease and its Risk Factors and Complications Subcommittees, with the task of reaching clear, specific and universally acceptable definitions of risks and complications. Members of this multidisciplinary taskforce formed organ-specific subcommittees that were charged with expanding the list of complications, when appropriate, as well as reaching consensus definitions within their organ-system subcommittee. Comprehensive definitions were obtained from existing professional organizations or consensus reports when available, and through consultation with organ specific experts. The list of complications and definitions were presented to the Multi-Societal Database Committee for final adjudication.

Gastrointestinal complications refer to complications associated with the organs that compose the gastrointestinal tract and those organs supplied by the celiac, superior mesenteric and inferior mesenteric arteries. These organs include the esophagus, stomach, small intestine, large intestine or colon, liver, gallbladder, spleen, and pancreas. These gastrointestinal complications are listed alphabetically in Table 1.

Table 1 Gastrointestinal complications – Final List. Precise definitions for these complications are given in Part 4 of the Supplement.

Organ-specific complications are further differentiated and defined by severity, which commonly reflects the need for intervention. For example, other than dysphagia, or the inability to eat, ischemic bowel likely represents one of the more common gastrointestinal complications. The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease proposes the following consensus definition for ischemic bowel:

“Ischemic bowel is defined as a reduction in the supply of oxygenated blood to the small intestine or large intestine, typically resulting in acidosis, abdominal distention, and feeding intolerance.”

Necrotizing enterocolitis reflects a similar pathophysiologic process; however, the diagnosis of necrotizing enterocolitis requires additional criteria about the diagnosis and associated treatments. Specifically, the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease proposes the following consensus definition for necrotizing enterocolitis:

“Necrotizing enterocolitis is defined as an acute reduction in the supply of oxygenated blood to the small intestine or large intestine, typically resulting in acidosis, abdominal distention, pneumatosis, and/or intestinal perforation, that prompts initiation of antibiotics or exploratory laparotomy.”

Necrotizing enterocolitis is further subclassified by location of involvement, that is either the small bowel or the large bowel. Similar differentiation and severity grading are also included for ascites, dysphagia, gastroesophageal reflux disease, gastrointestinal bleeding, and ileus, as shown in Table 1.

Controversies

Unlike diagnoses such as sepsis, renal failure, or respiratory failure, complications associated with the gastrointestinal system are, at times, less well defined, and often subjected to interpretation as to whether certain gastrointestinal morbidities are true “complications” or expected findings after congenital cardiac surgery. This dilemma is particularly apparent when interpreting feeding difficulties. Gastrointestinal complications may reflect functional outcomes which are identified without confirmatory diagnostic tools or a specific cause-effect relationship. For example, Table 1 identifies “Dysphagia and/or inability to eat” as a gastrointestinal complication. The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease proposes the following consensus definition for the complication of “Dysphagia and/or inability to eat”

“Dysphagia and/or inability to eat is defined as difficulty in swallowing or the inability to eat that may result in the need for parenteral nutrition, tube feedings, or gastrostomy or enterostomy feedings.”

This diagnosis is a relatively common gastrointestinal phenomenon after neonatal cardiac surgery, is often diagnosed through patient observation, and is subject to variable interpretation by the clinician. Further controversy arises when one attempts to relate the complication to a specific event, both as a cause-effect relationship and temporally. For example, inability to eat or difficulty swallowing may be due to multiple potentially contributory aetiologies:

  • • prolonged intubation

  • • neurologic injury incurred prior to surgery

  • • neurologic injury incurred during to surgery

  • • neurologic injury incurred after to surgery

  • • pre-existing abdominal pathology

  • • intestinal ischemia, or

  • • clinician preference not to feed due to a potential for aspiration in the presence of unilateral vocal cord paresis.

Similar discrepancies might also be present with the diagnosis of gastroesophageal reflux disease, which is often subjectively diagnosed without confirmatory diagnostics, and is an expected morbidity even in the healthy infant. These discrepancies may result in variable reporting of certain gastrointestinal complications and be prohibitive in identifying the incidence of specific complications and in future validation of the specific data about these complications.

Gastrointestinal interactions with the cardiac system

Gastrointestinal complications are largely attributed to ischemia and perfusion abnormalities of the splanchnic circulation and tissue dysoxia or shock. Shock-induced physiologic vulnerability is not limited to the intraoperative time, with or without the use cardiopulmonary bypass, but is also linked to events of ischemia and reperfusion which may occur during the preoperative and postoperative periods of time. Throughout the perioperative period, efficient delivery of oxygen to meet regional metabolic demands occurs through autoregulatory regional and global circulatory controls. Specifically, the regional flow of blood is determined by the interaction of neurohumoral factors related to inflammation and the sympathetic nervous system, and local factors related to autoregulation.Reference Hessel1, Reference Ackland, Grocott and Mythen5–Reference Jakob7 The sympathetic response to stress that evolved to deal with hypovolemic and septic shockReference Izzo and Taylor8, Reference Kimmerly and Shoemaker9 is activated in all states of shock to redistribute the flow of blood to the brain and heart.Reference Haljamae10 The organs supplied by the splanchnic circulation are the first to suffer ischemic injury because sympathetic outflow and innervation is rich in these regions,Reference Reilly, Wilkins, Fuh, Haglund and Bulkley11–Reference Meakins, Marshall, Marston, Buckley and Fiddian-Green13 and because of the selective vasoconstriction effects of angiotensin.Reference Aneman, Pettersson and Eisenhofer14, Reference Toung, Reilly, Fuh, Ferris and Bulkley15 The final common pathway seen with splanchnic ischemia includes the endogenous production of inflammatory mediators and the development of endotoxemia, which has been shown to instigate dysfunction of multiple organs and, potentially, death.Reference Deitch, Morrison, Berg and Specian16, Reference Marshall and Nathens17

Conclusions

A need exists for the accurate identification and measurement of complications of surgical care. To address this need for patients with congenital cardiac disease, the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease has worked to provide comprehensive standardized nomenclature for complications in this population.

The gastrointestinal system is prone to complication after surgery due to the interactions between the gastrointestinal and cardiovascular systems. However, the non-specific nature of many of the gastrointestinal complications, coupled with issues of correct identification and attribution of causality, creates ongoing challenges. The comprehensive list provided in this Supplement should be viewed as a starting point for ongoing efforts to increase the understanding of perioperative gastrointestinal complications.

Acknowledgement

We thank The Children’s Heart Foundation (http://www.childrensheartfoundation.org/) for financial support of this research.

References

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Figure 0

Table 1 Gastrointestinal complications – Final List. Precise definitions for these complications are given in Part 4 of the Supplement.