Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study*

Abstract

Mechanical ventilation is often used in children after cardiac surgery but can impair hemodynamics and cause lung injury. Early extubation may improve ICU length of stay and survival. We aimed to describe trends in early extubation rates and evaluate if centers that more commonly practice early extubation have better severity-adjusted outcomes. DESIGN:Retrospective analysis was performed of admissions in the Virtual Pediatric Systems (VPS, LLC) database from 2009 to 2018. Early extubation was defined as patients extubated in the operating room or within 6 hours of PICU admission. SETTING:PICUs participating in the VPS database. PATIENTS:Children in the VPS database who underwent cardiac surgery. INTERVENTIONS: None.MEASUREMENT AND MAIN RESULTS: Among 69,739 subjects, 20% were neonates, 47% underwent early extubation, 5.3% failed extubation, and 2.5% died. Overall, early extubation rates did not change over the study period. Centers were placed in one of four groups based on their early extubation rate in lower complexity surgeries. Centers that most commonly used early extubation had more ICU-free time among all patients in univariable analysis (lowest early extubation group, 23.8 d [interquartile range, 18.2-25.9 d]; highest early extubation group, 24.7 d [20.0-26.2 d]; p < 0.001). After adjusting for center volume, sex, age, surgical complexity, and preoperative ICU admission, increasing center-level early extubation rates were not associated with more ICU-free days. Higher center-level early extubation rate was not associated with mortality in univariable or multivariable analysis but was associated with decreased extubation failure rate (lowest early extubation group, 6.4%; highest early extubation group, 3.6%; p < 0.001). CONCLUSIONS:In this large, multicenter database study, early extubation rates in postoperative cardiac patients did not significantly change between 2009 and 2018. Centers that performed early extubation more frequently did not have shorter ICU stays or difference in mortality rates but did have lower reintubation rates.

Editor’s Choice Articles for July

“…Refresh your knowledge of PICU volume, intensive care practices, and invasive procedures in the 43 centers contributing to the United States Pediatric Health Information System database (2014 to 2019) (4). Have a detailed look at early extubation rates in postoperative cardiac surgery patients (as a group and stratified by age and severity) reported to the United States Virtual Pediatric Systems (VPS, LLC) database (2009 to 2018) (5). Next, see the other analysis from the VPS database, using 81 PICUs in the United States, to look at the interaction between timing of COVID-19−related school closures and what the authors call “standardized admission ratio” data (6).…”

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

“…As intensivists, we must continually reassess the available data, sources, and resultant findings to keep pace and improve the lives of the children for whom we provide care. We hope that the work by Epstein et al (4) will lead to further data-driven scrutiny of current practices as we work to establish novel future priorities in pediatric cardiac critical care medicine.…”

“…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.…”

“…As pediatric cardiac critical care evolves, natural progression supports the development of specific networks to promote data housing, collaboration, and examination of best practices, not unlike the Extracorporeal Life Support Organization. To that end, the Pediatric Cardiac Critical Care Consortium (PC 4 ) is gaining momentum in the field. PC 4 was formed in 2009 and currently includes 69 pediatric cardiac ICUs, including two international centers (10).…”

“…An additional strength of PC 4 is its alignment with the Society of Thoracic Surgeons Congenital Heart Surgery Database, as they both use the same registry solutions platform. Furthermore, PC 4 is now an integral component of Cardiac Networks United and part of a continuum of pediatric cardiac care.…”