A Multivariable Model Predictive of Unplanned Postoperative Intubation in Infant Surgical Patients

Abstract

BACKGROUND: Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures. METHODS: In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and peri-operative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012–2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve. RESULTS: In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85–0.87) for the derivation cohort and 0.83 (95% CI, 82–0.85) for the validation cohort. CONCLUSIONS: About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes. (Anesth Analg XXX;XXX:00–00)

Unplanned Postoperative Reintubation in Children with Bronchial Asthma

“…12,13 These two large retrospective cohort studies included asthma and chronic lung disease or chronic oxygen therapy in their initial model parameters. 11 In children, a history of asthma was associated with a 15% relative increase in the risk of early unplanned reintubation during the first 72 postoperative hours. There are several plausible explanations for the increase in unplanned postoperative reintubation in patients with asthma.…”

“…We adjusted the analysis for several variables used in previous publications. 10 11 We adjusted the analysis for several variables used in previous publications,10,11 which included age, at the time of surgery (adolescents ≥ 13 years, children 6–12 years, and young children 1–5 years), race (Caucasian, African American, other, unknown), gender, American Society of Anesthesiologists (ASA) physical classification (> 3 vs. ≤ 3), year of operation (2012–2017), complexity index of surgery (1 [lowest]–5 [highest]), and surgical specialty (general surgery, orthopaedic surgery, neurosurgery, urology, otolaryngology, and other). Surgical complexity index was obtained from a principal component analysis of duration of surgery and work relative value unit, which resulted in a first component that explained 75% of the variation in the dataset.…”

“…Up to 2.2% of pediatric patients require unplanned postoperative reintubation, 10 11 12 13 most of which may be preventable. 14 Unplanned postoperative reintubation predisposes surgical patients to a higher risk of mortality, morbidity, and longer length of hospital stay.…”

An Overview of Commonly Used Data Sources in Observational Research in Anesthesia

“…NSQIP data have been reported to be superior in tracking surgical care and outcomes, compared to claims data. 52 Studies using NSQIP data have looked into, for example, outcomes of sleep apnea surgeries, 27 utilization of regional anesthesia for clavicular fracture fixation surgeries, 28 prediction of unplanned preoperative intubation in pediatric patients, 53 and postoperative anemia in children. 30 Commonly mentioned limitations include the propensity toward selection bias as participation in NSQIP is voluntary with no compensation for entry of data.…”

Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion

“…The regression coefficients of the simplified model were used to compare the magnitude of each risk predictor, with the smallest regression coefficient used as a reference value (1 point) for assigning points in a risk score. Each factor was then assigned points based on how many multiples of the reference value were contained within its regression coefficient and rounded to the nearest integer, an approach previously used by our group and others 31,32 . Discrimination of our score was assessed using logistic regression of perioperative transfusion as predicted by the score, once again examining the area under the receiver operating characteristic curve.…”