Early Extubation Following Congenital Heart Surgery: Time to Move on*

Abstract

Care for pediatric surgery patients in North America has evolved exponentially over the past 5 decades (1). Once considered a lifelimiting condition, many patients with congenital heart disease survive well into adulthood, primarily from advances in care across the lifespan. Even before birth, enhancements in prenatal imaging allow for earlier detection of congenital heart defects. Newborns undergo pulse oximetry screening before discharge from the nursery, allowing for prompt referral to experts. The 40,000 children who undergo congenital heart operations annually receive around-the-clock care staffed by multidisciplinary teams in the state-of-theart pediatric cardiac ICUs. Improved durable mechanical circulatory devices provide a bridge to transplant or decision in children who fail palliative procedures or are not eligible for repair. As these children grow into adulthood, new subspecialties have developed to care for these adults facing complex medical and psychosocial needs. The common thread in all these advancements is improved surgical outcomes and a new focus on long-term developmental ones (2). An essential aspect of this evolution is the creation of Cardiac Networks United, which, according to its mission and vision (3): "aims to unite and align networks to advance research and improvement efforts through collaboration. "Hence, it is reasonable to assume that improvement in outcomes of pediatric cardiac surgery patients is most likely secondary to that evolution in the field, and especially our willingness to collaborate, share data, and learn from each other.With these advantages, we now have an opportunity to prioritize future goals and critically reevaluate the state of current practices, specifically by using established databases to enquire if these practices have achieved their stated goals and whether further investment in their use is justified.In this issue of Pediatric Critical Care Medicine, Epstein et al (4) tackle the concept of early postcardiac surgery extubation, a captivating goal that seemingly translates into improved outcomes. The authors describe their query of the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database on trends in extubation, hypothesizing that centers that practice early extubation more frequently had subsequent differences in mortality or ICU lengths of stay.VPS contains data on over 1 million PICU admissions from more than 130 hospitals (5). It includes a specific score for cardiac surgical patients, the Pediatric Index of Cardiac Surgical Mortality, which incorporates variables that better predict mortality in this unique patient population than do the Pediatric Index of Mortality-2 or the Pediatric Risk of .The breadth of this information suggests that enquiry using established databases such as VPS provides valuable multicenter details to the existing literature on this crucial question. The authors do not claim that early extubation should not occur if the patients' clinical state allows it. However, in the context of the