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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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Pardo AC, Carrasco M, Wintermark P, Nunes D, Chock VY, Sen S, Wusthoff CJ. Neuromonitoring practices for neonates with congenital heart disease: a scoping review. Pediatr Res 2024:10.1038/s41390-024-03484-x. [PMID: 39183308 DOI: 10.1038/s41390-024-03484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
Neonates with congenital heart disease (CHD) are at risk for adverse neurodevelopmental outcomes. This scoping review summarizes neuromonitoring methods in neonates with CHD. We identified 84 studies investigating the use of near-infrared spectroscopy (NIRS) (n = 37), electroencephalography (EEG) (n = 20), amplitude-integrated electroencephalography (aEEG) (n = 10), transcranial Doppler sonography (TCD) (n = 6), and multimodal monitoring (n = 11). NIRS was used to evaluate cerebral oxygenation, identify risk thresholds and adverse events in the intensive care unit (ICU), and outcomes. EEG was utilized to screen for seizures and to predict adverse outcomes. Studies of aEEG have focused on characterizing background patterns, detecting seizures, and outcomes. Studies of TCD have focused on correlation with short-term clinical outcomes. Multimodal monitoring studies characterized cerebral physiologic dynamics. Most of the studies were performed in single centers, had a limited number of neonates (range 3-183), demonstrated variability in neuromonitoring practices, and lacked standardized approaches to neurodevelopmental testing. We identified areas of improvement for future research: (1) large multicenter studies to evaluate developmental correlates of neuromonitoring practices; (2) guidelines to standardize neurodevelopmental testing methodologies; (3) research to address geographic variation in resource utilization; (4) integration and synchronization of multimodal monitoring; and (5) research to establish a standardized framework for neuromonitoring techniques across diverse settings. IMPACT: This scoping review summarizes the literature regarding neuromonitoring practices in neonates with congenital heart disease (CHD). The identification of low cerebral oxygenation thresholds with NIRS may be used to identify neonates at risk for adverse events in the ICU or adverse neurodevelopmental outcomes. Postoperative neuromonitoring with continuous EEG screening for subclinical seizures and status epilepticus, allow for early and appropriate therapy. Future studies should focus on enrolling larger multicenter cohorts of neonates with CHD with a standardized framework of neuromonitoring practices in this population. Postoperative neurodevelopmental testing should utilize standard assessments and testing intervals.
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Affiliation(s)
- Andrea C Pardo
- Department of Pediatrics (Neurology and Epilepsy). Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Melisa Carrasco
- Department of Neurology. University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Pia Wintermark
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, Qc, Canada
| | - Denise Nunes
- Galter Health Sciences Library. Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Valerie Y Chock
- Department of Pediatrics (Neonatology), Lucile Packard Children's Hospital and Stanford University, Palo Alto, CA, US
| | - Shawn Sen
- Department of Pediatrics (Neonatology). Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Pediatrics, University of California Irvine, Orange, CA, US
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Colak M, Ceylan G, Topal S, Sarac Sandal O, Atakul G, Soydan E, Sarı F, Hepduman P, Karaarslan U, Ağın H. Evaluation of renal near-infrared spectroscopy for predicting extubation outcomes in the pediatric intensive care setting. Front Pediatr 2024; 11:1326550. [PMID: 38313403 PMCID: PMC10834679 DOI: 10.3389/fped.2023.1326550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/11/2023] [Indexed: 02/06/2024] Open
Abstract
Background In pediatric intensive care units, extubation failure following invasive mechanical ventilation poses significant health risks. Determining readiness for extubation in children can minimize associated morbidity and mortality. This study investigates the potential role of renal near-infrared spectroscopy (RrSO2) in predicting extubation failure in pediatric patients. Methods A total of 84 patients aged between 1 month and 18 years, mechanically ventilated for at least 24 h, were included in this prospective study. RrSO2 levels were measured using near-infrared spectroscopy before and during an extubation readiness test (ERT). The primary outcome measure was extubation failure, defined as a need for reintubation within 48 h. Results Of the 84 patients, 71 (84.6%) were successfully extubated, while 13 (15.4%) failed extubation. RrSO2 was found to be lower in the failed extubation group, also decrease in RrSO2 values during ERT was significantly greater in patients with extubation failure. ROC analysis indicated a decrease in ΔRrSO2 of more than 6.15% from baseline as a significant predictor of extubation failure, with a sensitivity of 0.984 and a specificity of 0.889. Conclusion Monitoring changes in RrSO2 values may serve as a helpful tool to predict extubation failure in pediatric patients. Further multi-center research is warranted to improve the generalizability and reliability of these findings.
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Affiliation(s)
- Mustafa Colak
- Department of Paediatric Intensive Care Unit, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Gokhan Ceylan
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
- Department of Medical Research, Hamilton Medical AG, Bonaduz, Switzerland
| | - Sevgi Topal
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ozlem Sarac Sandal
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Gulhan Atakul
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ekin Soydan
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ferhat Sarı
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Pinar Hepduman
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Utku Karaarslan
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Hasan Ağın
- Department of Paediatric Intensive Care Unit, Dr Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
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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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Hames DL, Sleeper LA, Bullock KJ, Feins EN, Mills KI, Laussen PC, Salvin JW. Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery. Pediatr Crit Care Med 2022; 23:e208-e218. [PMID: 35184097 PMCID: PMC9058191 DOI: 10.1097/pcc.0000000000002912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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
OBJECTIVES Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT. DESIGN Retrospective cohort study. SETTING CICU at a tertiary-care children's hospital. PATIENTS Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01). CONCLUSIONS Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin J. Bullock
- Department of Respiratory Care, Boston Children’s Hospital, Boston, MA
| | - Eric N. Feins
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Peter C. Laussen
- Department of Anesthesia, Boston Children’s Hospital, Boston, MA
- Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
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