A parent’s touch reduces agitation, allows infants and toddlers to remain extubated after heart surgery.
A small percentage of babies and young children who have undergone congenital cardiac surgery and early tracheal extubation are treated with a calming parent’s touch at Nationwide Children’s Hospital – a strategy that physicians have found works better in some cases than escalating analgesics.
The Cardiothoracic Intensive Care Unit (CTICU) employs kangaroo care, a staple of the neonatal ICU, when infants and toddlers show rising markers of agitation and probable delirium.
The protocol was begun after researchers discovered a troubling pattern among children younger than 1 year of age who had undergone bypass surgery and early extubation from 2010 to 2013.
Nationwide Children’s pioneered the practice of early extubation and continues to study the impact of this technique on improving outcomes for these patients. The practice decreases exposure to medications, incidence of infection and pneumonia, length of hospital stay and provides other benefits for the great majority of infants.
Of 234 infants extubated in the operating room after surgery, however, 10 had rising markers of agitation and were treated with escalating analgesics. That led to respiratory depression, reintubation, associated morbidities and much longer hospital stays.
“One of the real difficulties in dealing with infants, because they can’t communicate, is understanding what agitation is,” says Peter Winch, MD, a cardiac anesthesiologist at Nationwide Children’s and first author of the extubation study – published in July in Pediatric Critical Care Medicine. “Treating these young children for pain was perhaps missing a broader problem of disorientation, or delirium.”
“The children awaken in a foreign environment with tubing and lines coming out of them and many different things going on at the same time,” says Ayman Naguib, MD, director of cardiac anesthesia in The Heart Center and the Department of Anesthesiology and Pain Management at Nationwide Children’s.
Staff in the CTICU have become experienced at telling the difference between pain and delirium, says Janet Simsic, MD, medical director of the CTICU in The Heart Center. Staff members use the pediatric analgesic emergence delirium scale and watch whether a child can focus on parents or medical staff. If narcotics increase agitation, that’s a sign that delirium, not pain, is the issue.
For infants or toddlers suffering delirium, Tylenol and Toradol replace narcotics, Dr. Simsic says. “If the parents are calming and willing, we put the child in an adult bed and let the parent lie next to them. A nurse watches over them, making sure all the lines, tubes and wires remain in place.”
The first time they tried kangaroo care, the baby calmed down and remained extubated, Dr. Winch says. It is now used on about two heart surgery patients per month.
“This,” Dr. Naguib says, “is a very big step toward achieving our goals.”
Winch PD, Staudt AM, Sebastian R, Corridore M, Tumin D, Simsic J, Galantowicz M, Naguib A, Tobias JD. Learning from experience: improving early tracheal extubation success after congenital cardiac surgery. Pediatric Critical Care Medicine 2016 Jul;17(7):630-637.
Photo credit: Nationwide Children’s