Characteristics and Hemodynamic Effects of Extubation Failure in Children Undergoing Complete Repair for Tetralogy of Fallot

Abstract

This study aimed to identify the prevalence, etiology, and outcomes of extubation failure in children after complete repair for tetralogy of Fallot at a single tertiary-care, academic children's hospital. The secondary aim of this study was to determine the cardiorespiratory effects of the transition from positive-pressure ventilation to spontaneous breathing in children with extubation success and extubation failure. For this study, extubation was defined as the need for reintubation within 96 h after extubation. Demographics as well as pre-, intra-, post-, and periextubation data were collected in a retrospective observational format for patients who underwent complete repair for tetralogy of Fallot during the period January 2001-June 2011. Patients with multiple aortopulmonary collateral arteries or associated complete atrioventricular septal defects were excluded from the study. The cardiorespiratory variables collected before and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near-infrared spectroscopy, oxygen saturations, and lactate levels. The clinical outcomes evaluated included the success or failure of extubation and the hospital length of stay. Descriptive and univariate statistics were used to compare the group with extubation failure and the group with extubation success. Extubation failure occurred for 7 % (12/164) of the 164 eligible patients during the study period. The median age of the patients at surgery was 200 days (range 98-356 days), and their median weight was 6.8 kg (range 5.2-8.5 kg). For 6 % (10/164) of the patients, intubation was performed before surgery. The median duration of mechanical ventilation was 33 h (range 19.5-73 h), and the median hospital stay was 10 days (range 7-15 days). Of the 12 patients with extubation failure, 2 had extubation failure in first 2 h after extubation, 6 had failure in 2-24 h, 3 had failure in 24-48 h, and 1 had failure in 48-96 h. The patients in the extubation success and extubation failure groups were similar in age, sex, and body weight at the time of surgery. All preexisting conditions also were similar in the two groups. The intraoperative variables and postoperative complications did not differ between the two groups. The hospital stay was longer for the children with extubation failure (p < 0.001). The partial pressure of oxygen in arterial blood (PaO2), tachycardia, mean arterial blood pressure, and inotrope score improved significantly at conversion from positive-pressure ventilation to spontaneous ventilation in the patients with extubation success. This study demonstrated that extubation failure in patients after complete repair for tetralogy of Fallot is low and that the etiology is diverse. The majority of extubation failures in these patients occurred in the first 24 h. Extubation success in the children after repair for tetralogy of Fallot was associated with improvement in PaO2, tachycardia, and mean arterial pressure, with a decrease in inotrope score. Extub...

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

“…In our study, extubation failure occurred in nearly one-fifth of neonates, which is consistent with the range of 10-27% reported in other studies of children recovering from pediatric cardiac surgery [10][11][12][13][14][15]. The definition of extubation failure has varied in prior studies examining extubation failure in children with cardiac disease [10][11][12][13][14][15], with some defining extubation failure as the need for re-intubation within 24-48 hours while others have used 96 hours as their definition. Authors who have employed the latter definition [13][14][15] have asserted that extubation failure in patients with underlying cardiac disease can be slow to evolve and thus the time frame for extubation failure should be expanded beyond 48 hours.…”

“…The definition of extubation failure has varied in prior studies examining extubation failure in children with cardiac disease [10][11][12][13][14][15], with some defining extubation failure as the need for re-intubation within 24-48 hours while others have used 96 hours as their definition. Authors who have employed the latter definition [13][14][15] have asserted that extubation failure in patients with underlying cardiac disease can be slow to evolve and thus the time frame for extubation failure should be expanded beyond 48 hours. We agreed with this latter sentiment though we opted to limit the definition to 72 hours based on anecdotal observations from quality assurance efforts at our institution, in which we have found extubation failure beyond 72 hours to be uncommon.…”

“…Extubation failure is often tumultuous in these patients, and can be associated with considerable postoperative morbidity and prolonged length of stay in the intensive care unit, especially in neonates [10]. To date, existing literature that has reported risk factors for extubation failure specific to patients recovering from pediatric cardiac surgery have been either large heterogeneous groups of children that ranged widely in age [11][12] or smaller studies focused on specific lesions [13][14][15]. We hypothesized that a study focused solely on neonates but inclusive of all neonatal cardiac lesions would not only identify patient characteristics associated with extubation failure but would also identify specific cardiac defects at increased risk for this undesirable outcome.…”

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU

“…Some authors (3, 11) used a different time period to define extubation failure (< 24 or for up to 96 hr after extubation), while others include use of noninvasive positive pressure ventilation as a criterion for failure (12, 18, 19). Our definition of extubation failure as need for reintubation within 48 hours is consistent with that in several other previous studies from both cardiac and general pediatric critical care populations (4–6).…”

“…Though other authors use variable time periods to define extubation failure (3, 11, 12), this investigative team believes that 48 hours is the most appropriate in the current era given the increasing use of noninvasive ventilation techniques that can decelerate the progression of respiratory failure. If a patient was extubated in the cardiac operating room and was subsequently reintubated in the CICU, this was recorded as an extubation failure.…”