Risk Factors for Extubation Failure After Pediatric Cardiac Surgery and Impact on Outcomes: A Multicenter Analysis

Abstract

IMPORTANCE: Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality. OBJECTIVES: We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included. MAIN OUTCOMES AND MEASURES: We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported. RESULTS: Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality. CONCLUSION AND RELEVANCE: Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducing EFs.

Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study

“…Failure of the transition to extubation is characterized by a need to re-intubate with MV support within 48 h. We observed an EF rate of 12.5% among the 335 enrolled pediatric patients, in excellent agreement with earlier reports of 2–20% in various similar studies. 8 , 9 , 10 , 11 Extubation readiness protocols are less well established for pediatric than adult patients, and definitive and reliable markers to extubate pediatric patients are lacking. 19 Therefore, the decision to extubate depends solely on the adequacy of the clinical assessment of patient medical status by the attending expert intensive care physician, and the conservative strategies used contribute to the variations observed in the EF rate in various hospital settings.…”

“… 7 Premature extubation, primary illness severity, etiological condition, prolonged PICU stay, prolonged use of analgesics and sedatives, and population demographics may result in 2–20% of EFs with associated unfavorable clinical outcomes and increased mortality, as reported in several studies. 8 , 9 , 10 , 11 Upper airway obstruction (UAO) is a major contributor to reported cases of EF caused by tracheal inflammation, glottis, and laryngeal edema, leading to distress and stridor. Other clinical factors include respiratory muscle weakness, diaphragm dysfunction, neurological impairment, and cardiac dysfunction.…”

Development of a clinical prediction tool for extubation failure in pediatric cardiac intensive care unit

“…The prevalence of extubation failure ranges from 5% to 35% ( 1 – 3 ). Various studies have demonstrated risk factors associated with extubation failure in pediatric patients, including genetic syndrome, younger age, prolonged mechanical ventilation, sedation of longer than five days, post-extubation stridor (PES), respiratory muscle weakness, uncuffed endotracheal tube use, and a set of positive end-expiratory pressure (PEEP) greater than 5 cmH 2 O ( 4 – 6 ).…”