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Hanson AE, Herrmann JL, Abu-Sultaneh S, Murphy LD, Mastropietro CW. Prospective Evaluation of Extubation Failure in Neonates and Infants After Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024:21501351241269869. [PMID: 39360469 DOI: 10.1177/21501351241269869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Background: Extubation failure and its associated complications are not uncommon after pediatric cardiac surgery, especially in neonates and young infants. We aimed to identify the frequency, etiologies, and clinical characteristics associated with extubation failure after cardiac surgery in neonates and young infants. Methods: We conducted a single center prospective observational study of patients ≤180 days undergoing cardiac surgery between June 2022 and May 2023 with at least one extubation attempt. Patients who failed extubation, defined as reintubation within 72 h of first extubation attempt, were compared with patients extubated successfully using χ2, Fisher exact, or Wilcoxon rank-sum tests as appropriate. Results: We prospectively enrolled 132 patients who met inclusion criteria, of which 11 (8.3%) failed extubation. Median time to reintubation was 25.5 h (range 0.4-55.8). Extubation failures occurring within 12 h (n = 4) were attributed to upper airway obstruction or apnea, whereas extubation failures occurring between 12 and 72 h (n = 7) were more likely to be due to intrinsic lung disease or cardiac dysfunction. Underlying genetic anomalies, greater weight relative to baseline at extubation, or receiving positive end expiratory pressure (PEEP) > 5 cmH2O at extubation were significantly associated with extubation failure. Conclusions: In this study of neonates and young infants recovering from cardiac surgery, etiologies of early versus later extubation failure involved different pathophysiology. We also identified weight relative to baseline and PEEP at extubation as possible modifiable targets for future investigations of extubation failure in this patient population.
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Affiliation(s)
- Amy E Hanson
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Indiana University School of Medicine, Section of Congenital Cardiac Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Samer Abu-Sultaneh
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Lee D Murphy
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Miller AG, Kumar KR, Adagarla BS, Haynes KE, Watts RM, Muddiman JL, Heath TS, Allareddy V, Rotta AT. Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants. Respir Care 2023; 69:respcare.11194. [PMID: 37491072 PMCID: PMC10753612 DOI: 10.4187/respcare.11194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs). METHODS We performed a retrospective study of children < 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables. RESULTS We studied 51 subjects, median age 44 (interquartile range 0.5-242) d and weight 3.7 (3-4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH < 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24-56] vs 62 [46-72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and FIO2 were higher in subjects who required re-intubation. CONCLUSIONS NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO2 , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.
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Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Karan R Kumar
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Bhargav S Adagarla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Kaitlyn E Haynes
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Rachel M Watts
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Jeanette L Muddiman
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Travis S Heath
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Veerajalandhar Allareddy
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Singh A, Mandal B, Negi S, Puri GD, Thingnam SKS. Ultrasonic prediction of weaning failure in children undergoing cardiac surgery: A prospective observational study. Ann Card Anaesth 2023; 26:281-287. [PMID: 37470526 PMCID: PMC10451141 DOI: 10.4103/aca.aca_113_22] [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: 06/28/2022] [Revised: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 07/21/2023] Open
Abstract
Background and Aim To assess the utility of ultrasonic markers like B-line score (LUS), diaphragm thickness (DT), thickening fraction (DTF), and excursion (DE) as predictors of weaning outcomes in children on mechanical ventilation (MV) after cardiac surgery. Methods This was a prospective observational study done in postcardiac surgical intensive care unit (ICU) of a tertiary care hospital. Children aged 1 month to 18 years, on MV after cardiac surgery from January to November 2017, were included. They were extubated after satisfying institutional weaning criteria. Ultrasound for LUS, DT, DTF, and DE was performed preoperatively, during pressure support ventilation (PSV) before extubation and 4 h after extubation. Results Patients were divided into weaning failure and success groups based on reintubation within 48 h of extubation. Of the 50 evaluated patients, 43 (86%) were weaned successfully and 7 (14%) had weaning failure. The left DTF during PSV was lower in patients weaning failure (0.00%, interquartile range (IQR) 0.00-14.28 vs 16.67%, IQR 8.33-22.20, P = 0. 012). The left DTF≤ 14.64% during PSV (area under receiver's operating curve 0.795, P = 0.014), 85% sensitivity, and 57% specificity (positive likelihood ratio 1.97, negative likelihood ratio 0.25) could predict weaning failure. Conclusion The left DTF during PSV is a good predictor of weaning failure in children on MV in postoperative ICU after congenital cardiac surgery. Take home message In children on mechanical ventilation after cardiac surgery, left DTF during pressure support ventilation is a good predictor of weaning failure.
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Affiliation(s)
- Avneet Singh
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Banashree Mandal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunder Negi
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Kumar Singh Thingnam
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Descriptors of Failed Extubation in Norwood Patients Using Physiologic Data Streaming. Pediatr Cardiol 2023; 44:396-403. [PMID: 36562780 DOI: 10.1007/s00246-022-03084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
The objective of this study is to evaluate the utility of high-frequency physiologic data during the extubation process and other clinical variables for describing the physiologic profile of extubation failure in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure. This is a single-center, retrospective analysis. Extubation events were collected from January 2016 until July 2021. Extubation failure was defined as the need for re-intubation within 48 h of extubation. The data included streaming heart rate, respiratory rate, blood pressure, arterial oxygen saturation, and cerebral/renal near-infrared spectroscopy (NIRS). The most recent blood laboratory results before extubation were also included. These markers, demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations. The analysis included 311 extubations. The extubation failure rate was 10%. According to univariable analyses, failed extubations were preceded by higher respiratory rates (p = 0.029), lower end-tidal CO2 (p = 0.009), lower pH (p = 0.043), lower serum bicarbonate (p = 0.030), and lower partial pressure of O2 (p = 0.022). In the first 10 min after extubation, the failed events were characterized by lower arterial (p = 0.028) and cerebral NIRS (p = 0.018) saturations. Failed events were associated with persistently lower values for cerebral NIRS 2 h post-extubation (p = 0.027). In multivariable analysis, vocal cord anomaly, cerebral NIRS at 10 min post-extubation, renal NIRS at pre-extubation and post-extubation, and end-tidal CO2 at pre-extubation remained as significant co-variables. Oximetric indices before, in the 10 min immediately after, and 2 h after extubation and vocal cords paralysis are associated with failed extubation events in patients with parallel circulation.
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Yao X, Wang J, Lu Y, Huang X, Du X, Sun F, Zhao Y, Xie F, Wang D, Liu C. Prediction and prognosis of reintubation after surgery for Stanford type A aortic dissection. Front Cardiovasc Med 2022; 9:1004005. [PMID: 36299868 PMCID: PMC9592067 DOI: 10.3389/fcvm.2022.1004005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/21/2022] [Indexed: 01/28/2023] Open
Abstract
Background Reintubation is a serious adverse respiratory event after Stanford type A aortic dissection surgery (AADS), however, published studies focused on reintubation after AADS are very limited worldwide. The objectives of the current study were to establish an early risk prediction model for reintubation after AADS and to clarify its relationship with short-term and long-term prognosis. Methods Patients undergoing AADS between 2016–2019 in a single institution were identified and divided into two groups based on whether reintubation was performed. Independent predictors were identified by univariable and multivariable analysis and a clinical prediction model was then established. Internal validation was performed using bootstrap method with 1,000 replications. The relationship between reintubation and clinical outcomes was determined by univariable and propensity score matching analysis. Results Reintubation were performed in 72 of the 492 included patients (14.6%). Three preoperative and one intraoperative predictors for reintubation were identified by multivariable analysis, including older age, smoking history, renal insufficiency and transfusion of intraoperative red blood cells. The model established using the above four predictors showed moderate discrimination (AUC = 0.753, 95% CI, [0.695–0.811]), good calibration (Hosmer-Lemeshow χ2 value = 3.282, P = 0.915) and clinical utility. Risk stratification was performed and three risk intervals were identified. Reintubation was closely associated with poorer in-hospital outcomes, however, no statistically significant association between reintubation and long-term outcomes has been observed in patients who were discharged successfully after surgery. Conclusions The requirement of reintubation after AADS is prevalent, closely related to adverse in-hospital outcomes, but there is no statistically significant association between reintubation and long-term outcomes. Predictors were identified and a risk model predicting reintubation was established, which may have clinical utility in early individualized risk assessment and targeted intervention.
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Affiliation(s)
- Xingxing Yao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin Wang
- Department of Cardiology, The Sixth People's Hospital of Luohe, Luohe, China
| | - Yang Lu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yangchao Zhao
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Yangchao Zhao
| | - Fei Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Fei Xie
| | - Dashuai Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Dashuai Wang
| | - Chao Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Chao Liu
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Ross FJ, Joffe DC, Landsem LM, Latham GJ. The Year in Review: Anesthesia for Congenital Heart Disease 2021. Semin Cardiothorac Vasc Anesth 2022; 26:129-139. [PMID: 35616475 DOI: 10.1177/10892532221095038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review focuses on the literature published during the calendar year 2021 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Four major themes are discussed, including cardiovascular disease in children with COVID-19, aortic valve repair and replacement, bleeding and coagulation, and enhanced recovery after surgery (ERAS).
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Affiliation(s)
- Faith J Ross
- Department of Anesthesiology and Pain Medicine, University of WashingtonSeattle Children's Hospital, Seattle, WA, USA
| | - Denise C Joffe
- Department of Anesthesiology and Pain Medicine, University of WashingtonSeattle Children's Hospital, Seattle, WA, USA
| | - Leah M Landsem
- Department of Anesthesiology and Pain Medicine, University of WashingtonSeattle Children's Hospital, Seattle, WA, USA
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, University of WashingtonSeattle Children's Hospital, Seattle, WA, USA
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