Extubation after cardiothoracic surgery in neonates, children, and young adults: One year of institutional experience

Abstract

OBJECTIVE:: Describe risk factors associated with successful and early extubation in the pediatric cardiac intensive care unit. DESIGN:: Retrospective chart review. SETTING:: University hospital, cardiac intensive care unit. MEASUREMENTS AND MAIN RESULTS:: Review of 212 consecutive surgical admissions from January 2003 to January 2004, excluding deaths. Preoperative, intraoperative, and postoperative variables were studied. Successful extubation was defined as no reintubation at any time during the cardiac intensive care unit course and early extubation was defined as mechanical ventilation </=24 hrs. Median subject age was 8 months (range, 1 day-25 yrs), with 57% <1 yr of age and 22% neonates. Fifty-eight (27%) were extubated in the operating room and 122 (58%) were extubated at <24 hrs (mean, 6.1 +/- 7.7 hrs). Only seven patients failed extubation: three in the operating room because of upper airway obstruction and four in the cardiac intensive care unit for acute respiratory failure associated with atelectasis (n = 2), ventricular dysfunction (n = 1), and arrhythmia (n = 1). There were no extubation failures in patients extubated >24 hrs after surgery. A history of prematurity (odds ratio [OR], 5.84, 2.29-14.9; p < .001), base excess (OR, 1.47, 1.27-1.70; p < .001), cardiopulmonary bypass time (OR, 1.01, 1.01 to -1.2; p < .05), and the need for surgical reintervention (OR, 18.29, 2.78 to -120.07; p < .05) were associated with intubation for >24 hrs. CONCLUSION:: Extubation without the need for reintubation can be achieved in nearly all children following cardiothoracic surgery. The majority of successful extubations can be achieved within 24 hrs of surgery.

Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery

“…For example, upper airway obstruction leading to extubation failure has been implicated in 2-4% of patients in studies focused on children recovering from cardiac surgery. [6][7][8] Interestingly, one of these studies, 4 of 7 patients who failed extubation did so in the operating room secondary to extrathoracic upper airway obstruction, 8 indicating, as also demonstrated in our report, that patients need not be endotracheally intubated for prolonged periods of time to experience post-extubation stridor. In two studies of patients requiring tracheostomy following cardiac surgery, extrathoracic upper airway obstruction followed by tracheostomy placement occurred in 0.2% and 0.5% of patients.…”

“…Upper airway obstruction has also been implicated as important contributor to extubation failure, which has been associated with increased morbidity and mortality in this patient population. [6][7][8] In the most severe cases, tracheostomy is required to facilitate long-term recovery. [9][10][11] Current literature cites wide-ranging incidences of upper airway obstruction in the non-cardiac pediatric ICU population from 5-40%.…”

Predictors of Early Extubation After Pediatric Cardiac Surgery: A Single-Center Prospective Observational Study

“…The treatment of this disorder includes traditional interventions such as hyperoxic hyperventilation, induced alkalosis, and inotropic support or specific treatments like inhaled nitric oxide [21]. As a result, pediatric intensivist tends to avoid EE in this group of patients and previous studies showed that preoperative PHT generally accepted as a risk factor for prolonged MV in children undergoing cardiac surgery [7,17,18]. Thirty percent of our patients had preoperative PHT.…”

“…During these hours, PICU is covered by pediatric residents. Hence, patients who underwent more complex surgeries are sometimes kept intubated over the night of the operation and extubated Previous studies showed that younger age at the time of cardiac surgery was associated with prolonged MV [17]. Neonatal and infantile age (especially younger than 6 months old) [7,17] has been recognized as a significant predictor of prolonged MV.…”

“…Hence, patients who underwent more complex surgeries are sometimes kept intubated over the night of the operation and extubated Previous studies showed that younger age at the time of cardiac surgery was associated with prolonged MV [17]. Neonatal and infantile age (especially younger than 6 months old) [7,17] has been recognized as a significant predictor of prolonged MV. The little contribution of the thoracic cage to respiratory function, the relatively weak intercostal muscles, and narrower airway in these age groups were shown to be the anatomical and physiologic reasons for the risk of prolonged MV [7].…”