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Abstract
OBJECTIVES Many hospitals aim to extubate children early after cardiac surgery, yet it remains unclear how this practice associates with extubation failure. We evaluated adjusted extubation failure rates and duration of postoperative mechanical ventilation across hospitals and assessed cardiac ICU organizational factors associated with extubation failure. DESIGN Secondary analysis of the Pediatric Cardiac Critical Care Consortium clinical registry. SETTING Pediatric Cardiac Critical Care Consortium cardiac ICUs. PATIENTS Patients with qualifying index surgical procedures from August 2014 to June 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We modeled hospital-level adjusted extubation failure rates using multivariable logistic regression. A previously validated Pediatric Cardiac Critical Care Consortium model was used to calculate adjusted postoperative mechanical ventilation. Observed-to-expected ratios for both metrics were derived for each hospital to assess performance. Hierarchical logistic regression was used to assess the association between cardiac ICU factors and extubation failure. Overall, 16,052 surgical hospitalizations were analyzed. Predictors of extubation failure (p < 0.05 in final case-mix adjustment model) included younger age, underweight, greater surgical complexity, airway anomaly, chromosomal anomaly/syndrome, longer cardiopulmonary bypass time, and other preoperative comorbidities. Three hospitals were better-than-expected outliers for extubation failure (95% CI around observed-to-expected < 1), and three hospitals were worse-than-expected (95% CI around observed-to-expected > 1). Two hospitals were better-than-expected outliers for both extubation failure and postoperative mechanical ventilation, and three were worse-than-expected for both. No hospital was an outlier in opposite directions. Greater nursing hours per patient day and percent nursing staff with critical care certification were associated with lower odds of extubation failure. Cardiac ICU factors such as fewer inexperienced nurses, greater percent critical care trained attendings, cardiac ICU-dedicated respiratory therapists, and fewer patients per cardiac ICU attending were not associated with lower odds of extubation failure. CONCLUSIONS We saw no evidence that hospitals trade higher extubation failure rates for shorter duration of postoperative mechanical ventilation after pediatric cardiac surgery. Increasing specialized cardiac ICU nursing hours per patient day may achieve better extubation outcomes and mitigate the impact of inexperienced nurses.
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Chaparro H, Abeldaño-Zuñiga RA. Factors associated with early extubation of patients after corrective tetralogy of Fallot. ENFERMERIA INTENSIVA 2018; 30:154-162. [PMID: 30509876 DOI: 10.1016/j.enfi.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. METHODS A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. RESULTS 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26). CONCLUSIONS Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.
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Affiliation(s)
- H Chaparro
- Hospital de Pediatría SAMIC, Juan P. Garrahan, Buenos Aires, Argentina
| | - R A Abeldaño-Zuñiga
- División de Estudios de Posgrado, Universidad de la Sierra Sur, Oaxaca, México.
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Silva-Cruz AL, Velarde-Jacay K, Carreazo NY, Escalante-Kanashiro R. Risk factors for extubation failure in the intensive care unit. Rev Bras Ter Intensiva 2018; 30:294-300. [PMID: 30304083 PMCID: PMC6180477 DOI: 10.5935/0103-507x.20180046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/11/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To determine the risk factors for extubation failure in the intensive care unit. METHODS The present case-control study was conducted in an intensive care unit. Failed extubations were used as cases, while successful extubations were used as controls. Extubation failure was defined as reintubation being required within the first 48 hours of extubation. RESULTS Out of a total of 956 patients who were admitted to the intensive care unit, 826 were subjected to mechanical ventilation (86%). There were 30 failed extubations and 120 successful extubations. The proportion of failed extubations was 5.32%. The risk factors found for failed extubations were a prolonged length of mechanical ventilation of greater than 7 days (OR = 3.84, 95%CI = 1.01 - 14.56, p = 0.04), time in the intensive care unit (OR = 1.04, 95%CI = 1.00 - 1.09, p = 0.03) and the use of sedatives for longer than 5 days (OR = 4.81, 95%CI = 1.28 - 18.02; p = 0.02). CONCLUSION Pediatric patients on mechanical ventilation were at greater risk of failed extubation if they spent more time in the intensive care unit and if they were subjected to prolonged mechanical ventilation (longer than 7 days) or greater amounts of sedative use.
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Affiliation(s)
| | - Karina Velarde-Jacay
- Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas - Lima, Perú
| | - Nilton Yhuri Carreazo
- Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas - Lima, Perú
| | - Raffo Escalante-Kanashiro
- Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas - Lima, Perú.,Unidad de Cuidados Intensivos, Instituto Nacional de Salud del Niño - Lima, Perú
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Abstract
OBJECTIVES 1) Determine the correlation between pulmonary dead space fraction and extubation success in postoperative pediatric cardiac patients; and 2) document the natural history of pulmonary dead space fractions, dynamic compliance, and airway resistance during the first 72 hours postoperatively in postoperative pediatric cardiac patients. DESIGN A retrospective chart review. SETTING Cardiac ICU in a quaternary care free-standing children's hospital. PATIENTS Twenty-nine with balanced single ventricle physiology, 61 with two ventricle physiology. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We collected data for all pediatric patients undergoing congenital cardiac surgery over a 14-month period during the first 72 hours postoperatively as well as prior to extubation. Overall, patients with successful extubations had lower preextubation dead space fractions and shorter lengths of stay. Single ventricle patients had higher initial postoperative and preextubation dead space fractions. Two-ventricle physiology patients had higher extubation failure rates if the preextubation dead space fraction was greater than 0.5, whereas single ventricle patients had similar extubation failure rates whether preextubation dead space fractions were less than or equal to 0.5 or greater than 0.5. Additionally, increasing initial dead space fraction values predicted prolonged mechanical ventilation times. Airway resistance and dynamic compliance were similar between those with successful extubations and those who failed. CONCLUSIONS Initial postoperative dead space fraction correlates with the length of mechanical ventilation in two ventricle patients but not in single ventricle patients. Lower preextubation dead space fractions are a strong predictor of successful extubation in two ventricle patients after cardiac surgery, but may not be as useful in single ventricle patients.
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56
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Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics Wayne State University Detroit, Michigan
| | - Girija Natarajan
- Department of Pediatrics Wayne State University Detroit, Michigan
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences Unit RTI International Rockville, Maryland
| | - Seetha Shankaran
- Department of Pediatrics Wayne State University Detroit, Michigan
| | - Waldemar A Carlo
- Department of Pediatrics University of Alabama at Birmingham Birmingham, Alabama
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Sood SB, Mushtaq N, Brown K, Littlefield V, Barton RP. Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation. J Pediatr Intensive Care 2018; 7:147-158. [PMID: 31073487 DOI: 10.1055/s-0038-1627099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/08/2017] [Indexed: 01/23/2023] Open
Abstract
Extubation failure is associated with considerable morbidity and mortality in postoperative patients with congenital heart disease (CHD). The study purpose was to investigate initial extubation success utilizing neurally adjusted ventilatory assist (NAVA) compared with pressure-regulated volume controlled, synchronized intermittent mandatory ventilation with pressure support (SIMV-PRVC + PS) for ventilatory weaning in patients who required prolonged mechanical ventilation (MV). Also, total days on MV, inotropes, sedation, analgesia, and pediatric intensive care unit (PICU) length of stay (LOS) between both groups were compared. This was a non-randomized pilot study utilizing historical controls (SIMV-PRVC + PS; n = 40) compared with a prospective study population (NAVA; n = 35) in a Level I PICU and was implemented to help future trial designs. All patients ( n = 75) required prolonged MV ≥96 hours due to their complex postoperative course. Ventilator weaning initiation and management was standardized between both groups. Ninety-seven percent of the NAVA group was successfully extubated on the initial attempt, while 80% were in the SIMV-PRVC + PS group ( p = 0.0317). Patients placed on NAVA were eight times more likely to have successful initial extubation (odds ratio [OR]: 8.50, 95% confidence interval [CI]: 1.01, 71.82). The NAVA group demonstrated a shorter median duration on MV (9.0 vs. 11.0 days, p = 0.032), PICU LOS (9.0 vs. 13.5 days, p < 0.0001), and shorter median duration of days on dopamine (8.0 vs. 11.0 days, p = 0.0022), milrinone (9.0 vs. 12.0 days, p = 0.0002), midazolam (8.0 vs. 12.0 days, p < 0.0001), and fentanyl (9.0 vs. 12.5 days, p < 0.0001) compared with the SIMV-PRVC + PS group. NAVA compared with SIMV-PRVC + PS was associated with a greater initial extubation success rate. NAVA should be considered as a mechanical ventilator weaning strategy in postoperative congenital heart disease (CHD) patients and warrants further investigation.
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Affiliation(s)
- Shawn Berry Sood
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Nasir Mushtaq
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Kellie Brown
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Vanette Littlefield
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Roger Phillip Barton
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
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Camargo Barros Rocha DA, Marson FAL, Almeida CCB, Almeida Junior AA, Ribeiro JD. Association between oxygenation and ventilation indices with the time on invasive mechanical ventilation in infants. Pulmonology 2018; 24:S2173-5115(17)30180-X. [PMID: 29398628 DOI: 10.1016/j.rppnen.2017.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 10/02/2017] [Accepted: 10/26/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) is a common practice in pediatric intensive care unit (PICU). However, the role of oxygenation (OI) and ventilation (VI) indices regarding the time on IMV has not been fully understood. BASIC PROCEDURES The study was conducted with infants up to 24 months of age, hospitalized in PICU for two consecutive years. The values of ventilatory parameters, OI, VI, and blood gas of infants, collected in the first seven days in IMV, were associated with the time on IMV. IMV was classified into: short (≤seven days) and long time (>seven days). The comparison was made from the first to the seventh day. Alpha=0.05. MAIN FINDINGS Of 142 infants [mean age=7.51±6.33 months], 59 (41.5%) remained on IMV for a short time and 83 (58.5%) for a long time. Differences in PaO2 values were found on the second day, and PaO2/FiO2 ratio on the second, third and fourth days, with higher values in the short-term IMV. For FiO2 from the second to the fifth day; Pinsp from the first to the seventh day; PEEP from the second to the sixth day; mechanical respiratory frequency from the second to the seventh day, PaCO2 on the second day; Paw from the first to the seventh day, OI from the second to the sixth day, and VI from the first to the seventh day, the values were higher in the long-term IMV. CONCLUSIONS The OI and VI can be considered as potential predictors of long-term IMV, along with other markers obtained during the IMV.
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Affiliation(s)
- D A Camargo Barros Rocha
- Department of Pediatrics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil
| | - F A L Marson
- Department of Pediatrics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil; Department of Medical Genetics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil.
| | - C C B Almeida
- Department of Pediatrics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil
| | - A A Almeida Junior
- Department of Pediatrics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil
| | - J D Ribeiro
- Department of Pediatrics, School of Medical Sciences, University of Campinas, CEP: 13081-970, P.O. Box: 6111 Campinas, São Paulo, Brazil.
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Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability. Pediatr Qual Saf 2017; 2:e047. [PMID: 30229183 PMCID: PMC6132888 DOI: 10.1097/pq9.0000000000000047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 10/21/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011. Methods The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012-13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line-associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias. Results A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3-4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias. Conclusions After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3-4 category procedures.
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Extubation Failure Is Associated With Increased Mortality Following First Stage Single Ventricle Reconstruction Operation. Pediatr Crit Care Med 2017; 18:1136-1144. [PMID: 28922269 DOI: 10.1097/pcc.0000000000001334] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify the prevalence, causes, risk factors, and outcomes associated with extubation failure following first stage single ventricle reconstruction surgery. DESIGN Retrospective cohort analysis of neonates who underwent a first stage single ventricle reconstruction operation. Extubation failure was defined as endotracheal reintubation within 48 hours of first extubation attempt. SETTING The Royal Children's Hospital, Melbourne. PATIENTS Data were collected for all infants who underwent a Norwood or Damus-Kaye-Stansel procedure between 2005 and 2014 at our institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extubation failure occurred in 23 of 137 neonates (16.8%; 95% CI, 11.0-24.1%) who underwent a trial of extubation. Overall, 42 patients (30.7%) were extubated to room air, 88 (64.2%) to nasal continuous positive airway pressure, and seven (5.1%) to high-flow nasal cannulae, though there was no major difference in extubation failure rates between these three groups (p = 0.37). The median time to reintubation was 16.7 hours (interquartile range, 3.2-35.2), and male infants failed extubation more frequently (63.2% vs 87.0%; p = 0.02), although age, gestation, weight, cardiac diagnosis (hypoplastic left heart syndrome vs other single ventricle conditions), shunt type (modified Blalock-Taussig vs right ventricle-pulmonary artery shunt), intraoperative perfusion times, preextubation mechanical ventilation duration, preextubation acid-base status, and postoperative fluid balance were not related to extubation outcome. Infants who failed extubation had a higher intensive care mortality (19.4% vs 3.5%; p = 0.03) and in-hospital mortality (30.4% vs 6.1%; p < 0.001). CONCLUSIONS There is a high prevalence of extubation failure following first stage single ventricle reconstruction, and this is associated with considerably worse patient outcomes. The high prevalence and also the wide variation in rates of extubation failure in reported literature provide with an opportunity for implementation of quality assurance activities to minimize this complication and improve outcomes.
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An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment. Pediatr Crit Care Med 2017; 18:e463-e471. [PMID: 28737600 DOI: 10.1097/pcc.0000000000001285] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist-led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU. DESIGN A quality improvement project. SETTING Single center, tertiary care Children's Hospital PICU. PATIENTS All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016. INTERVENTIONS A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation. MEASUREMENTS AND MAIN RESULTS We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015-January 2016), compared with 833 patients from the pre-daily spontaneous breathing trial period (February 2013-January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre-daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation. CONCLUSIONS An interprofessionally developed respiratory therapist-led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.
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Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation. J Pediatr 2017; 189:113-119.e2. [PMID: 28600154 PMCID: PMC5657557 DOI: 10.1016/j.jpeds.2017.04.050] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/20/2017] [Accepted: 04/24/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates. STUDY DESIGN This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation. RESULTS Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27). CONCLUSIONS Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities. TRIAL REGISTRATION ClinicalTrials.gov: NCT00233324.
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Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial. Pediatr Crit Care Med 2017; 18:e201-e206. [PMID: 28272175 DOI: 10.1097/pcc.0000000000001124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. DESIGN Double-blind, placebo-controlled randomized clinical trial. SETTING PICU in a tertiary referral center. PATIENTS Children 1 month to 15 years old who underwent mechanical ventilation. INTERVENTIONS Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. MEASUREMENTS AND MAIN RESULTS One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). CONCLUSIONS The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.
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Wang SH, Liou JY, Chen CY, Chou HC, Hsieh WS, Tsao PN. Risk Factors for Extubation Failure in Extremely Low Birth Weight Infants. Pediatr Neonatol 2017; 58:145-150. [PMID: 27349301 DOI: 10.1016/j.pedneo.2016.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/17/2015] [Accepted: 01/15/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although antenatal steroids and early use nasal continuous positive airway pressure (NCPAP) have significantly improved outcomes of neonatal respiratory distress syndrome, intubation with ventilator support is still commonly required in extremely low birth weight (ELBW) infants. The optimal timing of extubation in ELBW infants remains unclear. METHODS We retrospectively analyzed all ELBW preterm infants who were admitted to our neonatal intensive care unit (NICU) from January 2009 to December 2013. Demographic, ventilation, and arterial blood gas analysis results prior to and 2 hours after extubation were collected. Extubation failure was defined as reintubation due to deterioration of respiratory condition within 7 days after extubation. Risk factors for extubation failure were analyzed. RESULTS In total, 173 ELBW infants were born and admitted to our NICU during these 5 years. Among these 173 infants, 77 (44.5%) used NCPAP only during their hospitalization (20 diagnosed with chronic lung disease (CLD), 25.9%). Among the 95 patients that required intubation, 27 patients expired so extubation was not attempted. Sixteen of 68 (23.5%) survival cases required reintubation within 7 days after extubation. We found that gestational age, birth body weight, and sex ratio did not differ between the successful extubation group and the failed extubation group. Univariate analysis showed that the failed extubation group had a lower arterial pH right before and 2 hours after extubation, with a lower bicarbonate level after extubation. Further multivariate logistic regression analysis revealed an association between poor acid-base homeostasis 2 hours after extubation (pH < 7.3 and HCO3 < 18 mM/L) and extubation failure (odds ratio 4.56 and 6.187 and 95% confidence interval: 1.263∼16.462 and 1.68∼22.791, respectively). CONCLUSION This study shows that nearly half of ELBW infants do not require intubation. Among ELBW infants who require invasive ventilator support, those who have lower postextubation arterial pH and bicarbonate levels are at high risk of extubation failure.
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Affiliation(s)
- Shih-Hsin Wang
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan; Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jyun-You Liou
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan; The Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan.
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Schultheis JM, Heath TS, Turner DA. Association Between Deep Sedation from Continuous Intravenous Sedatives and Extubation Failures in Mechanically Ventilated Patients in the Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2017; 22:106-111. [DOI: 10.5863/1551-6776-22.2.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The primary objective of this study was to determine whether an association exists between deep sedation from continuous infusion sedatives and extubation failures in mechanically ventilated children. Secondary outcomes evaluated risk factors associated with deep sedation.
METHODS This was a retrospective cohort study conducted between January 1, 2009, and October 31, 2012, in the pediatric intensive care unit (PICU) at Duke Children's Hospital. Patients were included in the study if they had been admitted to the PICU, had been mechanically ventilated for ≥48 hours, and had received at least one continuous infusion benzodiazepine and/or opioid infusion for ≥24 hours. Patients were separated into 2 groups: those deeply sedated and those not deeply sedated. Deep sedation was defined as having at least one documented State Behavioral Scale (SBS) of −3 or −2 within 72 hours prior to planned extubation.
RESULTS A total of 108 patients were included in the analysis. Both groups were well matched with regard to baseline characteristics. For the primary outcome, there was no difference in extubation failures in those who were deeply sedated compared to those not deeply sedated (14 patients [22.6%] versus 7 patients [15.2%], respectively; p = 0.33). After adjusting for potential risk factors, patients with a higher weight percentile for age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00–1.03), lower Glasgow Coma Score (GCS) score prior to intubation (OR 0.85; 95% CI 0.74–0.97), and larger maximum benzodiazepine dose (OR 1.93; 95% CI 1.01–3.71) were associated with greater odds of deep sedation. A higher GCS prior to intubation was significantly associated with increased odds of extubation failure (OR 1.19; 95% CI 1.02–1.39).
CONCLUSIONS While there was no statistically significant difference in extubation failures between the 2 groups included in this study, considering the severe consequences of extubation failure, the numerical difference reported may be clinically important.
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Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis. J Pediatr 2017; 182:190-196.e4. [PMID: 28063686 DOI: 10.1016/j.jpeds.2016.12.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. STUDY DESIGN We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality. RESULTS We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13). CONCLUSIONS In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication.
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Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals. J Thorac Cardiovasc Surg 2017; 153:1519-1526. [PMID: 28259455 DOI: 10.1016/j.jtcvs.2016.12.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/20/2016] [Accepted: 12/30/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. METHODS We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. RESULTS The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18% had major extracardiac anomalies, and 74% underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95% confidence interval, 1.4-6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). CONCLUSIONS This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.
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Miura S, Hamamoto N, Osaki M, Nakano S, Miyakoshi C. Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk Factors. Ann Thorac Surg 2016; 103:1293-1298. [PMID: 27720369 DOI: 10.1016/j.athoracsur.2016.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/20/2016] [Accepted: 08/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose of this study was to explore the prevalence, etiology, and risk factors of extubation failure (EF) in post-cardiac surgery neonates. METHODS Neonates (30 days old or younger) who underwent cardiac surgery and were admitted to the cardiac intensive care unit between September 2010 and February 2016 were included. The prevalence and etiology of EF, defined as reintubation within 48 hours, were reviewed. Demographic, operative, and perioperative data were retrospectively collected. Multiple logistic regression models were constructed to identify the risk factors for EF. RESULTS The median age at surgery was 10 days. Extubation failure occurred in 25 of 156 cases (16.0%; 95% confidence interval: 10.6% to 22.7%), because of respiratory dysfunction (n = 16), hemodynamic instability (n = 4), upper airway obstruction (n = 4), or gastrointestinal bleeding (n = 1). Subsequent extubations were successful in 17 cases (68%) because of medical optimization of the causes of reintubation. The remaining 8 cases needed surgical reintervention, including tracheostomy and cardiac surgery. The inhospital mortality rate was 2.6%. In a bivariate analysis, younger age, airway diseases, ventilation before surgery, prolonged mechanical ventilation, and delayed sternal closure were associated with EF. The multivariable analysis identified airway diseases (adjusted odds ratio 18.2, 95% confidence interval: 3.8 to 88.6, p = 0.0003) and mechanical ventilation longer than 7 days (adjusted odds ratio 8.2, 95% confidence interval: 1.9 to 34.9, p = 0.0046) as risk factors for EF. CONCLUSIONS The prevalence of EF is relatively high in neonatal cardiac surgery. The etiologies can be diverse. Extubation of neonates at high risk after cardiac surgery, based on these possible risk factors, requires more diligent approaches.
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Affiliation(s)
- Shinya Miura
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan.
| | - Nao Hamamoto
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Osaki
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Nakano
- Department of Cardiac Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Chisato Miyakoshi
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan; School of Mathematics and Statistics, University of Sheffield, Sheffield, United Kingdom
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Jagannathan N, Shivazad A, Kolan M. Tracheal extubation in children with difficult airways: a descriptive cohort analysis. Paediatr Anaesth 2016; 26:372-7. [PMID: 26715011 DOI: 10.1111/pan.12837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events. AIMS The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways. METHODS A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥ 3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation. RESULTS A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were <10 kg in weight. Of these children, one child required emergency tracheostomy, and two children (one with tracheal stenosis and other with spinal muscular atrophy) suffered from hypoxemic cardiac arrest and anoxic brain damage, respectively, and eventually died. CONCLUSIONS In the studied population of children with difficult airways handled in a tertiary center environment, the majority of tracheal extubations could be performed without the use of airway adjuncts. In a minority of patients, tracheal extubation was associated with severe adverse outcomes.
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Affiliation(s)
- Narasimhan Jagannathan
- Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA
| | - Armin Shivazad
- Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA
| | - Michael Kolan
- Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA
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Jensen EA, DeMauro SB, Kornhauser M, Aghai ZH, Greenspan JS, Dysart KC. Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants. JAMA Pediatr 2015; 169:1011-7. [PMID: 26414549 PMCID: PMC6445387 DOI: 10.1001/jamapediatrics.2015.2401] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. OBJECTIVE To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. EXPOSURES The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. MAIN OUTCOMES AND MEASURES The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. RESULTS We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy. CONCLUSIONS AND RELEVANCE Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
| | | | - Zubair H. Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jay S. Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kevin C. Dysart
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
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Abstract
OBJECTIVE Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, although data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. DESIGN Retrospective chart review. SETTING Urban tertiary care free-standing children's hospital. PATIENTS Neonates (0-30 d) who underwent cardiac surgery at our institution between January 2009 and December 2012 was performed. INTERVENTIONS Extubation failure was defined as reintubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. MEASUREMENTS AND MAIN RESULTS We included 120 neonates, of whom 21 (17.5%) experienced extubation failure. On univariate analysis, patients who failed extubation were more likely to have genetic abnormalities (24% vs 6%; p = 0.023), hypoplastic left heart (43% vs 17%; p = 0.009), delayed sternal closure (38% vs 12%; p = 0.004), postoperative infection prior to extubation (38% vs 11%; p = 0.002), and longer duration of mechanical ventilation (median, 142 vs 58 hr; p = 0.009]. On multivariate analysis, genetic abnormalities, hypoplastic left heart, and postoperative infection remained independently associated with extubation failure. Furthermore, patients with infection who failed extubation tended to receive fewer days of antibiotics prior to their first extubation attempt when compared with patients with infection who did not fail extubation (4.9 ± 2.6 vs 7.3 ± 3; p = 0.073). CONCLUSIONS Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.
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The Ventilator Is a Vasoactive. Pediatr Crit Care Med 2015; 16:888-90. [PMID: 26536555 DOI: 10.1097/pcc.0000000000000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gaies M, Tabbutt S, Schwartz SM, Bird GL, Alten JA, Shekerdemian LS, Klugman D, Thiagarajan RR, Gaynor JW, Jacobs JP, Nicolson SC, Donohue JE, Yu S, Pasquali SK, Cooper DS. Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium. Pediatr Crit Care Med 2015; 16:837-45. [PMID: 26218260 PMCID: PMC4672991 DOI: 10.1097/pcc.0000000000000498] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. DESIGN Retrospective cohort study using prospectively collected clinical registry data. SETTING Pediatric Cardiac Critical Care Consortium registry. PATIENTS All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). CONCLUSIONS Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.
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Affiliation(s)
- Michael Gaies
- 1Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI. 2Department of Pediatrics, Benioff Children's Hospital and University of California San Francisco School of Medicine, San Francisco, CA. 3Department of Critical Care Medicine and Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, ON, Canada. 4Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 5Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL. 6Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. 7Department of Critical Care Medicine and Cardiology, Children's National Medical Center, Washington, DC. 8Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA. 9Division of Pediatric Cardiac Surgery, Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 11Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 12Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 13Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan Congenital Heart Center, Ann Arbor, MI. 14The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Al-Mandari H, Shalish W, Dempsey E, Keszler M, Davis PG, Sant'Anna G. International survey on periextubation practices in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2015; 100:F428-31. [PMID: 26063193 DOI: 10.1136/archdischild-2015-308549] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/15/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine periextubation practices in extremely preterm infants (<28 weeks gestation). DESIGN A survey consisting of 13 questions related to weaning from mechanical ventilation, assessment of extubation readiness and postextubation respiratory support was developed and sent to clinical directors of level III NICUs in Australia, Canada, Ireland, New Zealand and USA. A descriptive analysis of the results was performed. RESULTS 112/162 (69%) units responded; 36% reported having a guideline (31%) or written protocol (5%) for ventilator weaning. Extubation readiness was assessed based on ventilatory settings (98%), blood gases (92%) and the presence of clinical stability (86%). Only 54% ensured that infants received caffeine ≤24 h prior to extubation. 16% of units systematically extubated infants on the premise that they passed a Spontaneous Breathing Test with a duration ranging from 3 min (25%) to more than 10 min (35%). Nasal continuous positive airway pressure was the most common type of respiratory support used (84%) followed by nasal intermittent positive pressure ventilation (55%) and high-flow nasal cannula (33%). Reintubation was mainly based on clinical judgement of the responsible physician (88%). There was a lack of consensus on the time frame for definition of extubation failure (EF), the majority proposing a period between 24 and 72 h; 43% believed that EF is an independent risk factor for increased mortality and morbidity. CONCLUSIONS Periextubation practices vary considerably; decisions are frequently physician dependent and not evidence based. The definition of EF is variable and well-defined criteria for reintubation are rarely used. High-quality trials are required to inform guidelines and standardise periextubation practices.
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Affiliation(s)
- H Al-Mandari
- Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
| | - W Shalish
- Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
| | - E Dempsey
- Department of Paediatrics and Child Health, Cork University Maternity Hospital and Infant Centre, University College Cork, Wilton, Ireland
| | - M Keszler
- Department of Paediatrics, Brown University, Women and Infants Hospital, Providence, USA
| | - P G Davis
- Newborn Research, The Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - G Sant'Anna
- Department of Paediatrics, McGill University Health Center, Montreal Children's Hospital, Montreal, Canada
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Abstract
OBJECTIVE To determine the attributable hospital cost, both operational and departmental, and length of stay associated with unplanned extubations in children admitted to PICU and cardiac ICU. DESIGN Retrospective, matched case-control study. SETTING Forty-four-bed PICU and 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. PATIENTS Cases with an unplanned extubation were retrospectively identified from July 2011 to March 2013. Controls were PICU and cardiac ICU patients admitted over the same time period and were matched at a ratio of 2:1 for age and diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-eight unplanned extubations were analyzed. There were no differences in patient demographics between the two groups, except the control group had a higher severity of illness as illustrated by a larger Paediatric Index of Mortality II Risk of Mortality. Median total hospital costs were higher in those patients with unplanned extubations as compared with controls ($101,310 vs $64,618; p < 0.001). Patients with an unplanned extubation had longer median ICU length of stay (10 d vs 4.5 d; p < 0.001) and hospital length of stay (16.5 d vs 10 d, p < 0.001). CONCLUSION Pediatric patients with unplanned extubations have an associated increase in hospital costs ($36,692/case) and length of stay (6.5 d/case) as compared with age and diagnosis-matched controls. Further efforts are warranted to establish data-driven benchmarks and establishment of unplanned extubations as a critical metric for ICU quality.
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Valenzuela J, Araneda P, Cruces P. Weaning From Mechanical Ventilation in Paediatrics. State of the Art. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Grant MJC, Balas MC, Curley MAQ. Defining sedation-related adverse events in the pediatric intensive care unit. Heart Lung 2014; 42:171-6. [PMID: 23643411 DOI: 10.1016/j.hrtlng.2013.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/25/2013] [Accepted: 02/27/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry. OBJECTIVES To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial. METHODS In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates. RESULTS We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy. CONCLUSIONS Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.
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Affiliation(s)
- Mary Jo C Grant
- Pediatric Critical Care, Primary Children's Medical Center, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, USA.
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Joram N, Gaillard Le Roux B, Barrière F, Liet JM. Place des protocoles de sédation en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0818-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Optimizing patient-ventilator synchrony during invasive ventilator assist in children and infants remains a difficult task*. Pediatr Crit Care Med 2013; 14:e316-25. [PMID: 23842584 DOI: 10.1097/pcc.0b013e31828a8606] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To document and compare the prevalence of asynchrony events during invasive-assisted mechanical ventilation in pressure support mode and in neurally adjusted ventilatory assist in children. DESIGN Prospective, randomized, and crossover study. SETTING Pediatric and Neonatal Intensive Care Unit, University Hospital of Geneva, Switzerland. PATIENTS Intubated and mechanically ventilated children, between 4 weeks and 5 years old. INTERVENTIONS Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support, three levels of expiratory trigger setting were compared: expiratory trigger setting as set by the clinician in charge (PSinit), followed by a 10% (in absolute values) increase and decrease of the clinician's expiratory trigger setting. The pressure support session with the least number of asynchrony events was defined as PSbest. Therefore, three periods were compared: PSinit, PSbest, and neurally adjusted ventilatory assist. Asynchrony events, trigger delay, and inspiratory time in excess were quantified for each of them. MEASUREMENTS AND MAIN RESULTS Data from 19 children were analyzed. Main asynchrony events during PSinit were autotriggering (3.6 events/min [0.7-8.2]), ineffective efforts (1.2/min [0.6-5]), and premature cycling (3.5/min [1.3-4.9]). Their number was significantly reduced with PSbest: autotriggering 1.6/min (0.2-4.9), ineffective efforts 0.7/min (0-2.6), and premature cycling 2/min (0.1-3.1), p < 0.005 for each comparison. The median asynchrony index (total number of asynchronies/triggered and not triggered breaths ×100) was significantly different between PSinit and PSbest: 37.3% [19-47%] and 29% [24-43%], respectively, p < 0.005). With neurally adjusted ventilatory assist, all types of asynchrony events except double-triggering and inspiratory time in excess were significantly reduced resulting in an asynchrony index of 3.8% (2.4-15%) (p < 0.005 compared to PSbest). CONCLUSIONS Asynchrony events are frequent during pressure support in children despite adjusting the cycling off criteria. Neurally adjusted ventilatory assist allowed for an almost ten-fold reduction in asynchrony events. Further studies should determine the clinical impact of these findings.
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81
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Noninvasive ventilation for acute respiratory distress in children with central nervous system disorders. Respir Med 2013; 107:1370-5. [PMID: 23906815 DOI: 10.1016/j.rmed.2013.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/16/2013] [Accepted: 07/04/2013] [Indexed: 11/19/2022]
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Precup D, Robles-Rubio CA, Brown KA, Kanbar L, Kaczmarek J, Chawla S, Sant'Anna GM, Kearney RE. Prediction of extubation readiness in extreme preterm infants based on measures of cardiorespiratory variability. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2012:5630-3. [PMID: 23367206 DOI: 10.1109/embc.2012.6347271] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The majority of extreme preterm infants require endotracheal intubation and mechanical ventilation (ETT-MV) during the first days of life to survive. Unfortunately this therapy is associated with adverse clinical outcomes and consequently, it is desirable to remove ETT-MV as quickly as possible. However, about 25% of extubated infants will fail and require re-intubation which is also associated with a 5-fold increase in mortality and a longer stay in the intensive care unit. Therefore, the ultimate goal is to determine the optimal time for extubation that will minimize the duration of MV and maximize the chances of success. This paper presents a new objective predictor to assist clinicians in making this decision. The predictor uses a modern machine learning method (Support Vector Machines) to determine the combination of measures of cardiorespiratory variability, computed automatically, that best predicts extubation readiness. Our results demonstrate that this predictor accurately classified infants who would fail extubation.
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Affiliation(s)
- Doina Precup
- Department of Computer Science, McGill University, Montreal, Quebec, H3A 0E9, Canada.
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The use of near-infrared spectroscopy during an extubation readiness trial as a predictor of extubation outcome. Pediatr Crit Care Med 2013; 14:587-92. [PMID: 23823194 DOI: 10.1097/pcc.0b013e31828a8964] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether the measurement of cerebral and somatic regional oxygen saturation during an extubation readiness trial predicts extubation failure in postoperative cardiac patients. DESIGN Prospective observational study. SETTING Tertiary care center cardiac ICU. PATIENTS Pediatric patients 1 day to 21 years old following cardiac surgery for congenital heart disease. Patients were included if they were intubated for greater than 12 hours and were undergoing an extubation readiness trial. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data collection included patient demographic, procedural, laboratory, and physiologic variables. Regional oxygen saturation values were recorded using near-infrared spectroscopy at baseline, during a 2-hour extubation readiness trial, and in the first 2 hours postextubation. Ninety-nine extubation readiness trials were conducted in 79 patients. Adjusting for baseline somatic regional oxygen saturation, logistic regression analysis demonstrated that patients with a decline in their minimum somatic regional oxygen saturation of at least 10% during an extubation readiness trial had a 6-time increased odds of extubation failure (p = 0.02; 95% CI, 1.26-29.8). Receiver-operating characteristic curve analysis demonstrated that a 12% decline in the minimum regional oxygen saturation best predicted extubation failure with 54% sensitivity and 82% specificity. CONCLUSIONS A 12% decline in somatic regional oxygen saturation during an extubation readiness trial is associated with an increased risk of extubation failure following a successful extubation readiness trial. The addition of somatic regional oxygen saturation measurements to an extubation readiness trial may improve our ability to predict extubation outcome.
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84
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Laham JL, Breheny PJ, Rush A. Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit? J Intensive Care Med 2013; 30:89-96. [PMID: 23813884 DOI: 10.1177/0885066613494338] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CONTEXT There is absence of evidence-based guidelines to determine extubation readiness in the pediatric intensive care unit (PICU). OBJECTIVE Evaluate our practice of determining extubation readiness based on physician judgment of preextubation ventilator settings, blood gas analysis, and other factors potentially affecting extubation outcome. DESIGN Prospective cohort study from August 2010 to April 2012. SETTING Academic, multidisciplinary PICU. PATIENTS A total of 319 PICU patients undergoing first planned extubation attempt. INTERVENTIONS None. MEASUREMENTS Determine the extubation success rate and evaluate factors potentially affecting extubation outcome. The PICU length of stay (LOS) and cost were also recorded. Subgroup analysis was performed based on days of mechanical ventilation (MV). RESULTS A total of 319 consecutive patients underwent first planned extubation attempt with a 91% success rate. Factors associated with extubation failure were the length of MV (P < .0001, odds ratio [OR] 2.20); age (P = .02, OR 0.54); preextubation steroids (P = .04, OR 2.40); and postextubation stridor (P < .01, OR 3.40). Ventilator settings and blood gas results had no association with extubation outcome with 1 exception, ventilator rates ≤ 8 were associated with extubation failure in patients with ≤1 day of MV. Extubation failure was associated with prolonged PICU LOS and excess cost, with failures staying 14 days longer (P < .0001) and costing 3.2 time more (P < .0001) than successes. CONCLUSIONS Physician judgment to determine extubation readiness led to a first planned extubation success rate of 91%. Age and the length of MV were primary risk factors for failed extubation. In patients with ≤1 day of MV, our findings suggest that confidence in extubation readiness following weaning to low ventilator rates may not be justified. Furthermore, reliance on preextubation ventilator settings and blood gas results to determine extubation readiness may lead to unnecessary prolongation of MV, thereby increasing the PICU LOS and excess cost. These findings are hypothesis generating and require further study for confirmation.
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Affiliation(s)
- James L Laham
- St. Mary's Hospital, PICU/Pediatrics, Richmond, VA, USA
| | - Patrick J Breheny
- Department of Biostatistics, College of Public Health, University of Kentucky, Multidisciplinary Science Building, Lexington, KY, USA
| | - Amanda Rush
- Department of Pediatrics, University of Kentucky, Multidisciplinary Science Building, Lexington, KY, USA
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Chawla S, Natarajan G, Gelmini M, Kazzi SNJ. Role of spontaneous breathing trial in predicting successful extubation in premature infants. Pediatr Pulmonol 2013; 48:443-8. [PMID: 22811341 DOI: 10.1002/ppul.22623] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 04/16/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND The ability of clinicians to predict successful extubation in mechanically ventilated premature neonates is limited. Identifying objective criteria for predicting successful extubation may reduce the incidence of failed extubation and the duration of mechanical ventilation. OBJECTIVE To evaluate the validity of objective measures of lung function and spontaneous breathing trial (SBT) in predicting successful extubation among premature neonates with attempted extubations within the first 3 weeks of life. METHODS Respiratory compliance (Crs) along with SBT was performed prior to elective extubations within 3 weeks of age in premature infants ≤ 32 weeks. Extubation was considered successful if patients remained extubated for > 72 hr. Ventilator settings including mean airway pressure (MAP), set rate, and fraction of inspired oxygen (FiO₂) 24 hr after re-intubation were compared with pre-extubation settings, in patients requiring re-intubation. RESULTS Thirty-nine of 49 infants (80%) were successfully extubated. Of 41 babies who passed SBT, only 5 infants failed extubation. SBT had 92% sensitivity, 50% specificity, 88% positive predictive, and 63% negative predictive value for successful extubation. Crs was comparable between infants who were successfully extubated and those who were not. CONCLUSIONS A SBT prior to extubation may be a practical objective adjunct in predicting successful extubation in ventilated premature infants.
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Affiliation(s)
- Sanjay Chawla
- Division of Neonatal Perinatal Medicine, Hutzel Women's Hospital, Wayne State University, Detroit, Michigan 48201, USA.
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86
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Valenzuela J, Araneda P, Cruces P. Weaning from mechanical ventilation in paediatrics. State of the art. Arch Bronconeumol 2013; 50:105-12. [PMID: 23542044 DOI: 10.1016/j.arbres.2013.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/09/2013] [Accepted: 02/04/2013] [Indexed: 11/19/2022]
Abstract
Weaning from mechanical ventilation is one of the greatest volume and strength issues in evidence-based medicine in critically ill adults. In these patients, weaning protocols and daily interruption of sedation have been implemented, reducing the duration of mechanical ventilation and associated morbidity. In paediatrics, the information reported is less consistent, so that as yet there are no reliable criteria for weaning and extubation in this patient group. Several indices have been developed to predict the outcome of weaning. However, these have failed to replace clinical judgement, although some additional measurements could facilitate this decision.
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Affiliation(s)
- Jorge Valenzuela
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile; Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile.
| | - Patricio Araneda
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile
| | - Pablo Cruces
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile; Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andres Bello, Santiago, Chile
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Challapudi G, Natarajan G, Aggarwal S. Single-center Experience of Outcomes of Tracheostomy in Children with Congenital Heart Disease. CONGENIT HEART DIS 2013; 8:556-60. [DOI: 10.1111/chd.12048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Geetha Challapudi
- Division of Cardiology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
| | - Girija Natarajan
- Division of Neonatology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
| | - Sanjeev Aggarwal
- Division of Cardiology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
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Watkins SC, McNew BS, Donahue BS. Risks of Noncardiac Operations and Other Procedures in Children With Complex Congenital Heart Disease. Ann Thorac Surg 2013. [DOI: 10.1016/j.athoracsur.2012.09.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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89
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Prospective evaluation of sedation-related adverse events in pediatric patients ventilated for acute respiratory failure. Crit Care Med 2012; 40:1317-23. [PMID: 22425823 DOI: 10.1097/ccm.0b013e31823c8ae3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Sedation-related adverse events in critically ill pediatric patients lack reproducible operational definitions and reference standards. Understanding these adverse events is essential to improving the quality of patient care and for developing prevention strategies in critically ill children. The purpose of this study was to test operational definitions and estimate the rate and site-to-site heterogeneity of sedation-related adverse events. DESIGN Prospective cohort study. SETTING Twenty-two pediatric intensive care units in the United States enrolling baseline patients into a prerandomization phase of a multicenter trial on sedation management. PATIENTS Pediatric patients intubated and mechanically ventilated for acute respiratory failure. DATA EXTRACTION Analysis of adverse event data using consistent operational definitions from a Web-based data management system. MEASUREMENTS AND MAIN RESULTS There were 594 sedation-related adverse events reported in 308 subjects, for a rate of 1.9 adverse events per subject and 16.6 adverse events per 100 pediatric intensive care unit days. Fifty-four percent of subjects had at least one adverse event. Seven (1%) adverse events were classified as severe, 347 (58%) as moderate, and 240 (40%) as mild. Agitation (30% of subjects, 41% of events) and pain (27% of subjects, 29% of events) were the most frequently reported events. Eight percent of subjects (n = 24) experienced 54 episodes of clinically significant iatrogenic withdrawal. Unplanned endotracheal tube extubation occurred at a rate of 0.82 per 100 ventilator days, and 32 subjects experienced postextubation stridor. Adverse events with moderate intraclass correlation coefficients included: Inadequate sedation management (intraclass correlation coefficient = 0.130), clinically significant iatrogenic withdrawal (intraclass correlation coefficient = 0.088), inadequate pain management (intraclass correlation coefficient = 0.080), and postextubation stridor (intraclass correlation coefficient = 0.078). CONCLUSIONS Operational definitions for sedation-related adverse events were consistently applied across multiple pediatric intensive care units. Adverse event rates were different from what has been previously reported in single-center studies. Many adverse events have moderate intraclass correlation coefficients, signaling site-to-site heterogeneity.
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90
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Abstract
Managing the airway in the intensive care unit (ICU) is complicated by a wide array of physiologic factors. Difficult airway may be a consequence of patient’s anatomy or airway edema developed during the ICU stay and mechanical ventilation. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. In this article, we will provide a framework for identifying a difficult airway, criteria for safe extubation, as well as review the devices that are available for airway management in the ICU. Proficiency in identifying a potentially difficult airway and thorough familiarity with strategies and techniques of securing the airway are necessary for safe practice of critical care medicine
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Affiliation(s)
- Khaldoun Faris
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, MA, USA.
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Abstract
OBJECTIVE To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN Prospective cohort. SETTING Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.
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92
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Prolonged mechanical ventilation: does shorter duration of mechanical ventilation equal morbidity reduction for congenital heart disease patients? Pediatr Crit Care Med 2011; 12:368-9. [PMID: 21637153 DOI: 10.1097/pcc.0b013e3181f268be] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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93
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Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines. Pediatr Crit Care Med 2011; 12:65-70. [PMID: 20473241 DOI: 10.1097/pcc.0b013e3181e2a244] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation. DESIGN Observational study. SETTING Pediatric intensive care unit of a university hospital. PATIENTS A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8), with spontaneous cardiac rhythm. INTERVENTIONS Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed. MEASUREMENTS AND MAIN RESULTS After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35-40 torr, 4.6-5.3 kPa) in 70% of the cases upon arrival. CONCLUSIONS Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.
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Thammasitboon S, Rosen DA, Lutfi R, Ely BA, Weber MA, Hilvers PN, Gustafson RA. An institutional experience with epidural analgesia in children and young adults undergoing cardiac surgery. Paediatr Anaesth 2010; 20:720-6. [PMID: 20670235 DOI: 10.1111/j.1460-9592.2010.03339.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allowing spontaneous respiration after cardiac surgery eliminates complications related to mechanical ventilation and optimizes cardiopulmonary interaction. Epidural analgesia has been proposed to promote early extubation after cardiac surgery. OBJECTIVE To identify the characteristics of patients with epidural analgesia and safety profiles with respect to the timing of extubation following cardiac surgery. DESIGN AND METHOD A retrospective chart review of patients who underwent cardiac surgery during a 5-year period. Demographic, procedural, and perioperative variables were analyzed to investigate factors that affect the timing of extubation. RESULTS A total of 750 records were reviewed. The patients' median age was 12 months, and 52% were infants (<1 year). Seventy-five percent of the patients utilized cardiopulmonary bypass. The study population was classified into three groups according to the timing of extubation: 66% were extubated in the operating room or upon arrival at the PICU (Immediate), 15% were extubated within 24 h (mean, 10.8 h; 95% CI, 9.0-12.6) (Early), and 19% were extubated after 24 h (Delayed). For the Immediate and Early groups, multivariate logistic regression identified young age, increased cross-clamp time, and inotrope score as independent risk factors for the need for mechanical ventilation. Postextubation respiratory acidosis (mean P(a)CO(2), 50 mmHg; 95% CI, 49-51) was well tolerated by all patients. There were no neurologic complications related to the epidural technique. CONCLUSION Epidural analgesia in children undergoing cardiac surgery provides stable analgesia without complications in our experience.
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Edwards JD, Kun SS, Keens TG, Khemani RG, Moromisato DY. Children with corrected or palliated congenital heart disease on home mechanical ventilation. Pediatr Pulmonol 2010; 45:645-9. [PMID: 20575088 DOI: 10.1002/ppul.21214] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Infants and children with surgically corrected or palliated congenital heart disease (CHD) are at risk for chronic respiratory failure, necessitating home mechanical ventilation (HMV) via tracheostomy. However, very little data exists on this population or their outcomes. We conducted a retrospective chart review of all children with CHD enrolled in the Childrens Hospital Los Angeles HMV program between 1994 and 2009. Data were collected on type of heart lesion, surgeries performed, number of failed extubations, timing of tracheostomy, mortality, length of time on HMV, weaning status, associated co-morbidities, and Risk Adjusted classification for Congenital Heart Surgery (RACHS-1) category. Thirty-five children were identified; six with single ventricle anatomy, who received palliative procedures. Twenty-three (66%) patients are alive; 8 (23%) living patients have been weaned off HMV. Twelve (34%) patients are deceased. The incidence of mortality for single ventricle patients was 50%, and only one of the surviving children has received final palliation and weaned off HMV. Eight of nine patients (89%) with a RACHS score > or =4 died, and none have been weaned off of HMV. The 5-year survival for all CHD HMV patients was 68%; 90% for patients with RACHS < or =3; and 12% for patients with score > or =4. Children with more complex lesions, as demonstrated by single ventricle physiology or greater RACHS scores, had higher mortality rates and less success weaning off HMV. This case series suggests that caregivers should give serious consideration to the type of heart defect as they advise families considering HMV in children with CHD.
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Affiliation(s)
- Jeffrey D Edwards
- Department of Anesthesiology Critical Care Medicine, Childrens Hospital of Los Angeles, Los Angeles, CA, USA.
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Mayordomo-Colunga J, Medina A, Rey C, Concha A, Menéndez S, Los Arcos M, García I. Non invasive ventilation after extubation in paediatric patients: a preliminary study. BMC Pediatr 2010; 10:29. [PMID: 20444256 PMCID: PMC2876146 DOI: 10.1186/1471-2431-10-29] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 05/05/2010] [Indexed: 12/02/2022] Open
Abstract
Background Non-invasive ventilation (NIV) may be useful after extubation in children. Our objective was to determine postextubation NIV characteristics and to identify risk factors of postextubation NIV failure. Methods A prospective observational study was conducted in an 8-bed pediatric intensive care unit (PICU). Following PICU protocol, NIV was applied to patients who had been mechanically ventilated for over 12 hours considered at high-risk of extubation failure -elective NIV (eNIV), immediately after extubation- or those who developed respiratory failure within 48 hours after extubation -rescue NIV (rNIV)-. Patients were categorized in subgroups according to their main underlying conditions. NIV was deemed successful when reintubation was avoided. Logistic regression analysis was performed in order to identify predictors of NIV failure. Results There were 41 episodes (rNIV in 20 episodes). Success rate was 50% in rNIV and 81% in eNIV (p = 0.037). We found significant differences in univariate analysis between success and failure groups in respiratory rate (RR) decrease at 6 hours, FiO2 at 1 hour and PO2/FiO2 ratio at 6 hours. Neurologic condition was found to be associated with NIV failure. Multiple logistic regression analysis identified no variable as independent NIV outcome predictor. Conclusions Our data suggest that postextubation NIV seems to be useful in avoiding reintubation in high-risk children when applied immediately after extubation. NIV was more likely to fail when ARF has already developed (rNIV), when RR at 6 hours did not decrease and if oxygen requirements increased. Neurologic patients seem to be at higher risk of reintubation despite NIV use.
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Affiliation(s)
- Juan Mayordomo-Colunga
- Paediatric Intensive Care Unit, Department of Paediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain.
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Harikumar G, Egberongbe Y, Nadel S, Wheatley E, Moxham J, Greenough A, Rafferty GF. Tension-time index as a predictor of extubation outcome in ventilated children. Am J Respir Crit Care Med 2009; 180:982-8. [PMID: 19696443 PMCID: PMC2778157 DOI: 10.1164/rccm.200811-1725oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Accepted: 08/20/2009] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Indices that assess the load on the respiratory muscles, such as the tension-time index (TTI), may predict extubation outcome. OBJECTIVES To evaluate the performance of a noninvasive assessment of TTI, the respiratory muscle tension time index (TTmus), by comparison to that of the diaphragm tension time index (TTdi) and other predictors of extubation outcome in ventilated children. METHODS Eighty children (median [range] age 2.1 yr [0.15-16]) admitted to pediatric intensive care units at King's College and St Mary's Hospitals who required mechanical ventilation for more than 24 hours were studied. MEASUREMENTS AND MAIN RESULTS TTmus, maximal inspiratory pressure, respiratory drive, respiratory system mechanics, and functional residual capacity using a helium dilution technique, the rapid shallow breathing and CROP indices (compliance, rate, oxygenation, and pressure) indexed for body weight were measured and standard clinical data recorded in all patients. TTdi was measured in 28 of the 80 children using balloon catheters. Eight children (three in the TTdi group) failed extubation. TTmus (0.199 vs. 0.09) and TTdi (0.157 vs. 0.07) were significantly higher in children who failed extubation. TTmus greater than 0.18 (n = 80) and TTdi greater than 0.15 (n = 28) had sensitivities and specificities of 100% in predicting extubation failure. The other predictors performed less well. CONCLUSIONS Invasive and noninvasive measurements of TTI may provide accurate prediction of extubation outcome in mechanically ventilated children.
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Affiliation(s)
- Gopinathannair Harikumar
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - Yaya Egberongbe
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - Simon Nadel
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - Elizabeth Wheatley
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - John Moxham
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - Anne Greenough
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
| | - Gerrard F. Rafferty
- Department of Child Health, and Respiratory Medicine, King's College London, Division of Asthma, Allergy and Lung Biology, King's College London School of Medicine at Guy's, King's College and St Thomas' Hospitals; Paediatric Intensive Care Unit, and Aneasthetic Department and Intensive Care Unit, King's College Hospital NHS Trust; and Paediatric Intensive Care Unit, St Mary's Hospital NHS Trust, London, United Kingdom
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98
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Ong T, Stuart-Killion RB, Daniel BM, Presnell LB, Zhuo H, Matthay MA, Liu KD. Higher pulmonary dead space may predict prolonged mechanical ventilation after cardiac surgery. Pediatr Pulmonol 2009; 44:457-63. [PMID: 19382217 PMCID: PMC2768264 DOI: 10.1002/ppul.21009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Children undergoing congenital heart surgery are at risk for prolonged mechanical ventilation and length of hospital stay. We investigated the prognostic value of pulmonary dead space fraction as a non-invasive, physiologic marker in this population. In a prospective, cross-sectional study, we measured pulmonary dead space fraction in 52 intubated, pediatric patients within 24 hr postoperative from congenital heart surgery. Measurements were obtained with a bedside, non-invasive cardiac output (NICO) monitor (Respironics Novametrix, Inc., Wallingford, CT). Median pulmonary dead space fraction was 0.46 (25-75% IQR 0.34-0.55). Pulmonary dead space fraction significantly correlated with duration of mechanical ventilation and length of hospital stay in the entire cohort (r(s) = 0.51, P = 0.0002; r(s) = 0.51, P = 0.0002) and in the subset of patients without residual intracardiac shunting (r(s) = 0.45, P = 0.008; r(s) = 0.49, P = 0.004). In a multivariable logistic regression model, pulmonary dead space fraction remained an independent predictor for prolonged mechanical ventilation in the presence of cardiopulmonary bypass time and ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (OR 2.2; 95% CI 1.14-4.38; P = 0.02). The area under the receiver operator characteristic curve for this model was 0.91. Elevated pulmonary dead space fraction is associated with prolonged mechanical ventilation and hospital stay in pediatric patients who undergo surgery for congenital heart disease and has additive predictive value in identifying those at risk for longer duration of mechanical ventilation. Pulmonary dead space may be a useful prognostic tool for clinicians in patients who undergo congenital heart surgery.
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Affiliation(s)
- Thida Ong
- Division of Pediatric Pulmonary Medicine, University of California, San Francisco Children's Hospital, San Francisco, California 94143-0632, USA.
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99
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Saleem AF, Bano S, Haque A. Does prophylactic use of dexamethasone have a role in reducing post extubation stridor and reintubation in children? Indian J Pediatr 2009; 76:555-7. [PMID: 19390815 DOI: 10.1007/s12098-009-0067-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 07/28/2008] [Indexed: 10/20/2022]
Abstract
All children aged from 4 weeks to <5 year, were intubated for at least 48 hours [n=51] during 6 months. Data of the patients treated with DEX (0.5 ml/kg every 6 hours for 3 doses, beginning 6-12 hours prior to extubation) (n=30) were compared with control patients (who had not received medication) (n=21). The DEX and control groups were similar in age i.e., mean ages of DEX group were 16.85+/-14 months, and that of control group were 19.02 +/- 19 months, mean duration of intubation and mechanical ventilation in DEX group was 5.17 +/- 4.58 days, and that in control group was 3.98 +/- 3.60 days. There was no significant difference between DEX and control group in the incidence of postextubation stridor [17% (5/30) vs. 10% (2/21); p = 0.5] and the reintubation rate [7% (2/30) vs. 10% (2/21); p = 0.7]. Our data revealed that the prophylactic use of dexamethasone in planned extubation of high risk children were not effective.
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Affiliation(s)
- Ali Faisal Saleem
- Department of Material and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
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100
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Abstract
OBJECTIVE A systematic review of weaning and extubation for pediatric patients on mechanical ventilation. DATA SELECTION Pediatric and adult literature, English language. STUDY SELECTION Invited review. DATA SOURCES Literature review using National Library of Medicine PubMed from January 1972 until April 2008, earlier cross-referenced article citations, the Cochrane Database of Systematic Reviews, and the Internet. CONCLUSIONS Despite the importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are even less clear, although a trial of spontaneous breathing would seem a prerequisite. Several indices have been developed in an attempt to predict weaning and extubation success but the available literature would suggest they offer no improvement over clinical judgment. Extubation failure rates range from 2% to 20% and bear little relationship to the duration of mechanical ventilation. Upper airway obstruction is the single most common cause of extubation failure. A reliable method of assessing readiness for weaning and predicting extubation success is not evident from the pediatric literature.
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