Effects of on-Table Extubation after Pediatric Cardiac Surgery

Abstract

Background: Enhanced recovery after surgery (ERAS) protocols are utilizing a multidisciplinary approach, reassessing physiology to improve clinical outcomes, reducing length of hospital stay (LOS) stay, resulting in cost reduction. Since its introduction in colorectal surgery. the concept has been utilized in various fields and benefits have been recognized also in adult cardiac surgery. However, ERAS concepts in pediatric cardiac surgery are not yet widely established. Therefore, the aim of the present study was to assess the effects of on-table extubation (OTE) after pediatric cardiac surgery compared to the standard approach of delayed extubation (DET) during intensive care treatment. Study Design and Methods: We performed a retrospective analysis of all pediatric cardiac surgery cases performed in children below the age of two years using cardiopulmonary bypass at our institution in 2021. Exclusion criteria were emergency and off pump surgeries as well as children already ventilated preoperatively. Results: OTE children were older (267.3 days vs. 126.7 days, p < 0.001), had a higher body weight (7.0 ± 1.6 kg vs. 4.9 ± 1.9 kg, p < 0.001), showed significantly reduced duration of ICU treatment (75.9 ± 56.8 h vs. 217.2 ± 211.4 h, p < 0.001) and LOS (11.1 ± 10.2 days vs. 20.1 ± 23.4 days; p = 0.001) compared to DET group. Furthermore, OTE children had significantly fewer catecholamine dependencies at 12-, 24-, 48-, and 72-h post-surgery, while DET children showed a significantly increased intrafluid shift relative to body weight (109.1 ± 82.0 mL/kg body weight vs. 63.0 ± 63.0 mL/kg body weight, p < 0.001). After propensity score matching considering age, weight, bypass duration, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STATS)-Score, and the outcome variables, including duration of ICU treatment, catecholamine dependencies, and hospital LOS, findings significantly favored the OTE group. Conclusion: Our results suggest that on-table extubation after pediatric cardiac surgery is feasible and in our cohort was associated with a favorable postoperative course.

Of storks and babies and secondary analyses

“…The authors included only children with AV‐canal defects (21%), non‐restrictive VSDs (39%), and Fallot type of congenital heart disease (40%) for all of whom such protocols are available leading to safe and early (on the table) extubation with superior clinical results. Baehner et al described a significant shorter stay on the pediatric intensive care unit, less inotropes, less fluids and avoidance of prolonged postoperative ventilation in children extubated immediately after surgery for congenital heart disease 8 . The patient cohort in the current study could potentially have been extubated in the operating room without a risk of increased morbidity.…”

“…Baehner et al described a significant shorter stay on the pediatric intensive care unit, less inotropes, less fluids and avoidance of prolonged postoperative ventilation in children extubated immediately after surgery for congenital heart disease. 8 The patient cohort in the current study could potentially have been extubated in the operating room without a risk of increased morbidity. "On the table" extubation is an increasing practice in pediatric cardiac surgery.…”

Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery

“…Pulmonary hypertension or a better risk for possible postoperative pulmonary hypertension crisis was often cited as an argument for prolonged postoperative ventilation in children after cardiac surgery. However, a recent study revealed that the reasons for reintubation after extubation in the operating room following pediatric cardiac surgery were bleeding or insufficient respiration but not pulmonary hypertension crisis [ 18 ].…”

Perioperative and Anesthetic Considerations in Shone’s Complex

“…Broadly speaking for those who have undergone CPB surgical cases, those with minimal inotropic and ventilatory requirements should be considered candidates for early extubation (in the operating room or within 6 hours after surgery), even those with pulmonary hypertension. [58][59][60][61] A meta-analysis of studies thus far found that early extubation in pediatric cardiac surgical patients is not associated with adverse outcomes and may reduce in-hospital morbidity and mortality. 61 Most coarctation patients who present for surgery in stable condition are able to be extubated after surgical repair.…”