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Elmitwalli I, Abdelhady E, Kalsotra S, Gehred A, Tobias JD, Olbrecht VA. Use of high-flow nasal cannula versus other noninvasive ventilation techniques or conventional oxygen therapy for respiratory support following pediatric cardiac surgery: A systematic review and meta-analysis. Paediatr Anaesth 2024; 34:519-531. [PMID: 38389199 DOI: 10.1111/pan.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Noninvasive respiratory support may be provided to decrease the risk of postextubation failure following surgery. Despite these efforts, approximately 3%-27% of infants and children still experience respiratory failure after tracheal extubation following cardiac surgery. This systematic review evaluates studies comparing the efficacy of high-flow nasal cannula to conventional oxygen therapy such as nasal cannula and other noninvasive ventilation techniques in preventing postextubation failure in this patient population. METHODS A systematic and comprehensive search was conducted in major databases including MEDLINE, EMBASE, Web of Science, and Central. The search encompassed articles focusing on the prophylactic use of high-flow nasal cannula following tracheal extubation in pediatric patients undergoing cardiac surgery for congenital heart disease. The inclusion criteria for this review consisted of randomized clinical trials as well as observational, cohort, and case-control studies. RESULTS A total of 1295 studies were screened and 12 studies met the inclusion criteria. These 12 studies included a total of 1565 children, classified into three groups: seven studies compared high-flow nasal cannula to noninvasive ventilation techniques, four studies compared high-flow nasal cannula to conventional oxygen therapy, and one observational single-arm study explored the use of high-flow nasal cannula with no control group. There was no significant difference in the incidence of tracheal reintubation between high-flow nasal cannula and conventional oxygen therapy (risk ratio [RR] = 0.67, 95% confidence interval [CI]: 0.24-1.90, p = .46). However, there was a lower incidence of tracheal reintubation in patients who were extubated to high-flow nasal cannula versus those extubated to noninvasive ventilation techniques (RR = 0.45, 95% CI: 0.32-0.63, p < .01). The high-flow nasal cannula group also demonstrated a lower mortality rate compared to the noninvasive ventilation techniques group (RR = 0.31, 95% CI: 0.16-0.61, p < .01) as well as a shorter postoperative length of stay (mean difference = -8.76 days, 95% CI: -13.08 to -4.45, p < .01) and shorter intensive care length of stay (mean difference = -4.63 days, 95% CI: -9.16 to -0.11, p = .04). CONCLUSION High-flow nasal cannula is more effective in reducing the rate of postextubation failure compared to other forms of noninvasive ventilation techniques following surgery for congenital heart disease in pediatric-aged patients. high-flow nasal cannula is also associated with lower mortality rates and shorter length of stay. However, when comparing high-flow nasal cannula to conventional oxygen therapy, the findings were inconclusive primarily due to a limited number of scientific studies available on this specific comparison. Future study is needed to further define the benefit of high-flow nasal cannula compared to conventional oxygen therapy and various types of noninvasive ventilation techniques.
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Affiliation(s)
- Islam Elmitwalli
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Wilson HC, Gunsaulus ME, Owens GE, Goldstein SA, Yu S, Lowery RE, Olive MK. Failed Extubation in Neonates After Cardiac Surgery: A Single-Center, Retrospective Study. Pediatr Crit Care Med 2023; 24:e547-e555. [PMID: 37219966 DOI: 10.1097/pcc.0000000000003283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To describe factors associated with failed extubation (FE) in neonates following cardiovascular surgery, and the relationship with clinical outcomes. DESIGN Retrospective cohort study. SETTING Twenty-bed pediatric cardiac ICU (PCICU) in an academic tertiary care children's hospital. PATIENTS Neonates admitted to the PCICU following cardiac surgery between July 2015 and June 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients who experienced FE were compared with patients who were successfully extubated. Variables associated with FE ( p < 0.05) from univariate analysis were considered for inclusion in multivariable logistic regression. Univariate associations of FE with clinical outcomes were also examined. Of 240 patients, 40 (17%) experienced FE. Univariate analyses revealed associations of FE with upper airway (UA) abnormality (25% vs 8%, p = 0.003) and delayed sternal closure (50% vs 24%, p = 0.001). There were weaker associations of FE with hypoplastic left heart syndrome (25% vs 13%, p = 0.04), postoperative ventilation greater than 7 days (33% vs 15%, p = 0.01), Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5 operations (38% vs 21%, p = 0.02), and respiratory rate during spontaneous breathing trial (median 42 vs 37 breaths/min, p = 0.01). In multivariable analysis, UA abnormalities (adjusted odds ratio [AOR] 3.5; 95% CI, 1.4-9.0), postoperative ventilation greater than 7 days (AOR 2.3; 95% CI, 1.0-5.2), and STAT category 5 operations (AOR 2.4; 95% CI, 1.1-5.2) were independently associated with FE. FE was also associated with unplanned reoperation/reintervention during hospital course (38% vs 22%, p = 0.04), longer hospitalization (median 29 vs 16.5 d, p < 0.0001), and in-hospital mortality (13% vs 3%, p = 0.02). CONCLUSIONS FE in neonates occurs relatively commonly following cardiac surgery and is associated with adverse clinical outcomes. Additional data are needed to further optimize periextubation decision-making in patients with multiple clinical factors associated with FE.
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Affiliation(s)
- Hunter C Wilson
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Megan E Gunsaulus
- Division of Cardiology, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gabe E Owens
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Stephanie A Goldstein
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Mary K Olive
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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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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Miura S, Butt W, Thompson J, Namachivayam SP. Recurrent Extubation Failure Following Neonatal Cardiac Surgery Is Associated with Increased Mortality. Pediatr Cardiol 2021; 42:1149-1156. [PMID: 33864485 PMCID: PMC8052939 DOI: 10.1007/s00246-021-02593-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/31/2021] [Indexed: 11/25/2022]
Abstract
Extubation failure (EF) following neonatal cardiac surgery is associated with increased mortality. Neonates who experienced EF twice or more (recurrent EF) may have worse outcomes than those who have a single EF or no-EF. The aims of this study are to investigate the in hospital mortality for neonates with recurrent EF compared to those with single or no-EF, and determine factors associated with recurrent EF. Neonates' ≤ 28 days who underwent cardiac surgery from January 2008 to December 2019 were included. EF was defined as unplanned reintubation within 72 h after a planned extubation. 1187 (18 recurrent EF, 84 single EF and 1085 no-EF) neonates were included. Recurrent EF occurred in 18 (17.6%) of 102 neonates undergoing a second extubation. The median time (IQR) to reintubation after the first and second extubations were similar, being 20.9 (3.3-45.2) versus 19.4 (5.5-47) h. The reason for a second-time EF was respiratory in 39% and cardiovascular in 33%. Recurrent EF and single EF was associated with increased mortality (odds ratio, 95% confidence interval (CI) 23.5, 6.9-79.9) and (odds ratio, 95% CI 5.2, 2.3-12.0) compared to no-EF. Based on the final model with risk adjustment, predicted mortality was 29.0% in recurrent EF, 6.5% in single EF, and 1.2% in no-EF. First-time EF due to cardiovascular compromise was associated with recurrent EF (odds ratio, 95% CI 3.1, 1.0-9.7). This study confirmed that patients with recurrent EF have a high morality. Neonates with a cardiovascular reason for first-time EF are more likely to have a recurrent EF than those with other causes.
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Affiliation(s)
- Shinya Miura
- The Royal Children's Hospital Melbourne, Paediatric Intensive Care Unit, Melbourne, Australia.
| | - Warwick Butt
- The Royal Children's Hospital Melbourne, Paediatric Intensive Care Unit, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Jenny Thompson
- The Royal Children's Hospital Melbourne, Paediatric Intensive Care Unit, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Siva P Namachivayam
- The Royal Children's Hospital Melbourne, Paediatric Intensive Care Unit, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Extubation Failure and Major Adverse Events Secondary to Extubation Failure Following Neonatal Cardiac Surgery. Pediatr Crit Care Med 2020; 21:e1119-e1125. [PMID: 32804741 DOI: 10.1097/pcc.0000000000002470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. DESIGN A single-center cohort study. SETTING A medical-surgical, 30-bed PICU in Victoria, Australia. PATIENTS One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest (n = 10), chest reopening (n = 8), extracorporeal membrane oxygenation (n = 5), and death (n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction (n = 3), pulmonary overcirculation (n = 2), coronary ischemia (n = 2), cardiac tamponade (n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9; 95% CI: 1.1-32.2) and airway anomaly (odds ratio 6.0; 95% CI: 1.1-32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. CONCLUSIONS Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Garg RK, Thareen JK, Ramaiah AK, Di Donato RM. On-Table Extubation After Norwood Operation. J Cardiothorac Vasc Anesth 2019; 33:2760-2762. [DOI: 10.1053/j.jvca.2019.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 11/11/2022]
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Butt W. Extubation Failure After Cardiac Surgery: Can It Be Used As a Metric for Quality Improvement and/or Comparison of Patient Outcomes. Pediatr Crit Care Med 2019; 20:495-496. [PMID: 31058789 DOI: 10.1097/pcc.0000000000001905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Warwick Butt
- Intensive Care Unit, Royal Childrens Hospital Melbourne;, Department Paediatrics, University of Melbourne; and Clinical Sciences Theme, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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Huang SC, Huang CH. Commentary: Faster recovery after complex neonatal cardiac surgery. J Thorac Cardiovasc Surg 2019; 157:1601-1602. [DOI: 10.1016/j.jtcvs.2018.11.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 11/26/2022]
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