Children’s Memorial Hermann Hospital
Risk of Surgery
The risk of surgery is a topic most people would rather not think about. Unfortunately, risk is a reality for the families of children undergoing heart surgery; especially for patients who will be placed on the heart-lung machine (cardiopulmonary bypass). Even though it is not the most pleasant of topics, at Children’s Memorial Hermann Hospital, we feel that it is important that risks be understood by families.
Any part of the body can be adversely affected as a result of open heart surgery. Therefore, it becomes impossible to list every possible complication for an upcoming surgery. A more realistic approach is to discuss the overall risk of major complications, minor complications and a few relevant complications associated with a particular procedure.
Risk of major complications: Major complications are those from which a patient has a prolonged recovery or never recovers, such as stroke, seizures, kidney or liver damage, major infection, or death. Fortunately, this risk is low (less than 3 percent) for many open heart operations. However, risk of surgery is very different for every patient and procedure. Your child’s risk will be told to you honestly and up-front during your initial consultation with the pediatric cardiac surgeons.
Risk of minor complications: Minor complications are those from which a patient fully recovers within a relatively short period of time. Examples include a minor infection, an internal fluid collection which requires drainage as a bedside procedure, or irregular heartbeats which resolve with medication and treatment.
“Minor” complications rarely seem minor while they occur. They are only considered minor after they have completely resolved and everyone is assured that it will not occur again. It is important for families to realize that minor complications are relatively common in pediatric heart surgery. Every effort will be made to avoid complications in the first place; however, if they should occur they will be discussed with you openly and realistically.
Relevant individual complications: The complications that may occur with different procedures will vary widely between the procedures. Some procedures, unfortunately, have a high risk of patient death from the operation, while others have a very low risk.
Certain procedures have risks to a particular heart valve, others with leaving a leftover hole between heart chambers, others with too much or too little blood flow to the lungs, etc. Although all parts of the body are affected by heart surgery, the particularly important complications associated with your child’s individual procedure will be discussed so you have the best possible understanding of the risks involved.
Fortunately, most heart surgery is free of significant complications. Thus, there are no truly “common complications.” However, there are certain complications of which families need to be aware which arise more than others. Some of these are listed below:
- Need for pacemaker: The upper and lower chambers of the heart beat in sync because of a small nerve which transmits an electrical signal from the upper to the lower part of the heart. This nerve is located in a part of the heart very close to where many children have their surgical repairs. This nerve is microscopic and cannot be seen at the time of surgery; passing a suture around this nerve may injure it permanently and require a pacemaker. Although the need for a pacemaker must be considered a serious complication, children lead very normal lives with pacemakers and have virtually unrestricted activities.
- Residual VSD: Many pediatric heart surgeries involve closing a hole between the right and left ventricles (right and left-sided pumping chambers). Holes between the two pumping chambers are called ventricular septal defects, or VSDs. Thus, a leftover hole between the two pumping chamber is called a residual VSD. There is often a small hole left between the pumping chambers. Fortunately, it is very uncommon to have a leftover hole which is large enough to be a problem for the child. Most are small and may eventually close on their own.
- Repeat heart surgery: Access to the heart is, generally speaking, fairly easy for someone’s first heart surgery. The heart beats freely within its own sac, called the “pericardium,” and can be accessed without difficulty. However, scar tissue forms around the heart after the first surgery and for all subsequent surgeries. Sometimes, a heart chamber or major blood vessel can be heavily scared to a surrounding structure (such as the chest wall), and significant bleeding may result in an effort to divide the scar tissue. Risk of serious bleeding is actually fairly small with repeat heart surgery (fewer than 5 percent), but this special complication of repeat heart surgery must be considered each time.
- Pleural effusion/chylothorax: Patients normally weep fluid in the chest around the lungs after heart surgery. All patients undergoing heart surgery have drainage tubes left in place to collect this fluid. When the drainage from the tubes becomes minimal, the tubes are removed. Occasionally, after tubes are removed some fluid unexpectedly builds up; this is termed a pleural effusion. The drainage tube must be replaced, which is typically done at the bedside with sedation. Occasionally, the cause for the fluid build-up has to do with leaking of lymphatic fluid within the chest; this is termed a chylothorax. Rarely, patients may need to remain in the hospital for more than a week until the drainage decreases to the point where the tubes can be permanently removed. Patients with chylothorax are sometimes treated with a low-fat diet to decrease the drainage. Almost always, a pleural effusion or chylothorax is a temporary complication which has no long-term significance.
- Tachycardia: Irregular heart beats occur occasionally after heart surgery. One form of irregular heart beats are rapid heart beats, called tachycardia. The most common form of tachycardia in small children is called junctional ectopic tachycardia, or JET, which can virtually always be treated successfully with medication.
After surgery, infants and children will return to the intensive care unit (ICU) to be closely monitored during recovery period.
While your child is in the ICU, special equipment will be used to help him/her recover and may include the following:
- Ventilator – A machine that helps your child breathe. While he/she is under anesthesia during the operation, a small, plastic tube is guided into the windpipe and attached to the ventilator, which breathes for your child while he/she is too sleepy to breathe effectively on his/her own. After open heart surgery, some children will benefit from remaining on the ventilator overnight or even longer. Other children may be removed from the ventilator the same afternoon as surgery.
- Intravenous (IV) catheters - Small, plastic tubes inserted through the skin into blood vessels to provide IV fluids and important medicines that help your child recover from the operation.
- Arterial line - A specialized IV placed in the wrist or other area of the body where a pulse can be felt, that measures blood pressure continuously during surgery and while your child is in the ICU.
- Nasogastric (NG) tube - A small, flexible tube that keeps the stomach drained of acid and gas bubbles that may build up during surgery.
- Urinary catheter - A small, flexible tube that allows urine to drain out of the bladder and accurately measures how much urine the body makes, which helps determine how well the heart is functioning. After surgery, the heart will be a little weaker than it was before, and, therefore, the body may start to hold onto fluid, causing swelling and puffiness. Diuretics may be given to help the kidneys to remove excess fluid from the body. Urinary catheters are often called “Foley catheters.
- Chest tube - A drainage tube may be inserted to keep the chest free of blood that would otherwise accumulate after the incision is closed. Bleeding may occur for several hours, or even a few days after surgery.
- Heart monitor - A machine that constantly displays a picture of your child's heart rhythm, and monitors heart rate, arterial blood pressure and other values.
Your child may need other equipment not mentioned here to provide support while in the ICU, or afterwards. The hospital staff will explain all of the necessary equipment to you.
Your child will be kept as comfortable as possible with several different medications; some which relieve pain, and some which relieve anxiety. The staff will also be asking for your input as to how best to soothe and comfort your child.
After discharged from the ICU, your child will recuperate on another hospital unit for several days before going home. You will learn how to care for your child at home before your child is discharged. Your child may need to take medications for a while, and these will be explained to you. The staff will give you written instructions regarding medications, activity limitations, and follow-up appointments before your child is discharged.
Infants who spent a lot of time on a ventilator, or who were fairly ill while in the ICU, may have trouble feeding initially. These babies may have an oral aversion; they might equate something placed in the mouth, such as a pacifier or bottle, with a less pleasant sensation such as being on the ventilator. Some infants are just tired, and need to build their strength up before they will be able to learn to bottle-feed. Strategies used to help infants with nutrition include the following:
- Supplemental tube feedings: Feedings given through a small, flexible tube that passes through the nose, down the esophagus, and into the stomach, that can either supplement or take the place of bottle feedings. Infants who can drink part of their bottle, but not all, may be fed the remainder through the feeding tube. Infants who are too tired to bottle feed at all may receive their formula or breast milk through the feeding tube alone.
- High-calorie formula or breast milk: Special nutritional supplements may be added to formula or pumped breast milk that increase the number of calories in each ounce, thereby allowing your baby to drink less and still consume enough calories to grow.
Note: This information is meant to be a helpful, informative introduction on the subject of post-operative care. This information may not be applicable to all cases, especially if there are additional defects. It is not meant to replace the opinion of a personal physician.