Factors Associated With Unplanned Post-Craniotomy Re-intubation in Children: A NSQIP-Pediatric ® Analysis

Preoperative neurologic comorbidity and unanticipated early postoperative reintubation: a multicentre cohort study

BACKGROUND

The risk of respiratory complications is highest in the first 72 h post-surgery. Postoperative respiratory events can exacerbate pre-existing respiratory compromise and lead to reintubation of the trachea, particularly in patients with neurologic disorders. This study examined the association between neurologic comorbidities and unanticipated early postoperative reintubation in children.

METHODS

This multicentre, 1:1 propensity score-matched study included 420 096 children who underwent inpatient, elective, noncardiac surgery at National Surgical Quality Improvement Program reporting hospitals in 2012-22. The primary outcome was unanticipated early postoperative reintubation within 72 h after surgery. The secondary outcome was prolonged postoperative mechanical ventilation, defined as ventilator use >72 h. We also evaluated 30-day mortality in patients requiring reintubation.

RESULTS

Cerebral palsy was associated with the highest risk of early reintubation (adjusted relative risk [RRadj]: 1.97, 95% confidence interval [CI]: 1.44-2.69; P<0.01), followed by seizure disorders (RRadj: 1.87, 95% CI: 1.50-2.34; P<0.01), neuromuscular disorders (RRadj: 1.76, 95% CI: 1.41-2.19; P<0.01), and structural central nervous system abnormalities (RRadj: 1.35, 95% CI: 1.13-1.61; P<0.01). Unanticipated early postoperative reintubation was associated with an eight-times increased risk of 30-day mortality (adjusted hazard ratio: 8.1, 95% CI: 6.0-11.1; P<0.01). Risk of prolonged postoperative mechanical ventilation was also increased with neurologic comorbidities, particularly seizure disorders (RRadj: 1.73, 95% CI: 1.55-1.93; P<0.01).

CONCLUSIONS

Children with neurologic comorbidities have an increased risk of unanticipated early postoperative reintubation and prolonged mechanical ventilation. Given the high mortality risk associated with these outcomes, children with neurologic comorbidities require heightened monitoring and risk assessment.

Advances in pediatric neuroanesthesia practices

The field of pediatric neuroanesthesia has evolved with concurrent changes in pediatric neurosurgical practice. Ongoing pediatric neuroanesthesia investigations provide novel insights into developmental cerebrovascular physiology, neurosurgical technology, and clinical outcomes. Minimally invasive neurosurgical procedures appear to be associated with lower complication rates and length of stay. This review will discuss blood sparing techniques, regional anesthesia, and postoperative disposition. Collectively, these innovations appear to be safe in pediatric neurosurgical patients with potential benefits, but more data is needed for more definitive long-term outcomes.

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

BACKGROUND

Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year.

METHODS/INTERVENTION

A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods.

RESULTS

Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001].

CONCLUSIONS

Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness.

TYPE OF STUDY

Prospective Quality Improvement.

LEVEL OF EVIDENCE

Level III.

Frailty predicts hospital acquired infections after brain tumor resection: Analysis of 27,947 patients' data from a prospective multicenter surgical registry

BACKGROUND

Hospital acquired infections (HAIs) present a significant source of economic burden in the United States. The role of frailty as a predictor of HAIs has not been illustrated among patients undergoing craniotomy for brain tumor resection (BTR).

METHODS

The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2015 to 2019 to identify patients who underwent craniotomy for BTR. Patients were categorized as pre-frail, frail and severely frail using the 5-factor Modified Frailty Index (mFI-5). Demographics, clinical and laboratory parameters, and HAIs were assessed. A multivariate logistic regression model was created to predict the occurrence of HAIs using these variables.

RESULTS

A total of 27,947 patients were assessed. 1772 (6.3 %) of these patients developed an HAI after surgery. Severely frail patients were more likely to develop an HAI in comparison to pre-frail patients (OR = 2.48, 95 % CI = 1.65-3.74, p < 0.001 vs. OR = 1.43, 95 % CI = 1.18-1.72, p < 0.001). Ventilator dependence was the strongest predictor of developing an HAI (OR = 2.96, 95 % CI = 1.86-4.71, p < 0.001).

CONCLUSION

Baseline frailty, by virtue of its ability to predict HAIs, should be utilized in adopting measures to reduce the incidence of HAIs.

Hypercarbia in a Pediatric Patient With Relapsed Medulloblastoma

Pediatric medulloblastoma is a common form of pediatric brain tumor and typically presents with progressive signs of increased intracranial pressure and ataxia. Relapse of the disease is most often diagnosed on surveillance imaging. We present the case of a 13-year-old boy with a previous history of medulloblastoma who presented with chronic hypercarbic respiratory failure as a symptom of a recurrent tumor. Imaging demonstrated a left cerebellar enhancing mass with leptomeningeal thickness and extension to the posterior medulla oblongata, which is the center for respiratory control. His hypercarbic respiratory failure represents a unique presentation of a central nervous system (CNS) tumor. Thus, this case illustrates the importance of thorough evaluation for CNS tumors involving the brainstem in patients with respiratory acidosis and no clear pulmonary etiology.