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Miller AG, Brown J, Marshburn O, Mattin D, Muddiman J, Kumar KR, Allareddy V, Rotta AT. Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease. Respir Care 2024; 69:407-414. [PMID: 38164566 PMCID: PMC11108117 DOI: 10.4187/respcare.11312] [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] [Indexed: 01/03/2024]
Abstract
BACKGROUND In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters. METHODS Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success. RESULTS A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success. CONCLUSIONS ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.
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Affiliation(s)
- Andrew G Miller
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
| | - Jessica Brown
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Olivia Marshburn
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Dirk Mattin
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeanette Muddiman
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Karan R Kumar
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Veerajalandhar Allareddy
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Alexandre T Rotta
- Mr Miller, Dr Kumar, Dr Allareddy, and Dr Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina. Mr Miller, Ms Brown, Ms Marshburn, Mr. Mattin, and Ms Muddiman are affiliated with the Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Dr Kumar is affiliated with the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Acosta S, Hassan AM, Gugala Z, Karagoli Z, Hochstetler J, Kiskaddon AL, Checchia P, Faraoni D, Zheng F, Savorgnan F. Higher Cumulative Dose of Opioids and Other Sedatives are Associated with Extubation Failure in Norwood Patients. Pediatr Cardiol 2024; 45:8-13. [PMID: 37880385 DOI: 10.1007/s00246-023-03318-3] [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: 08/01/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The primary purpose of this study is to evaluate the relationship between sedation usage and extubation failure, and to control for the effects of hemodynamic, oximetric indices, clinical characteristics, ventilatory settings pre- and post-extubation, and echocardiographic (echo) findings in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure. METHODS Single-center, retrospective analysis of Norwood patients during their first extubation post-surgery from January 2015 to July 2021. Extubation failure was defined as reintubation within 48 h of extubation. Demographics, clinical characteristics, ventilatory settings, echo findings (right ventricular function, tricuspid regurgitation), and cumulative dose of sedation medications before extubation were compared between patients with successful or failed extubation. RESULTS The analysis included 130 patients who underwent the Norwood procedure with 121 (93%) successful and 9 (7%) failed extubations. Univariate analyses showed that vocal cord anomaly (p = 0.05), lower end-tidal CO2 (p < 0.01), lower pulse-to-respiratory quotient (p = 0.02), and ketamine administration (p = 0.04) were associated with extubation failure. The use of opioids, benzodiazepines, dexmedetomidine, and ketamine are mutually correlated in this cohort. On multivariable analysis, the vocal cord anomaly (OR = 7.31, 95% CI 1.25-42.78, p = 0.027), pre-extubation end-tidal CO2 (OR = 0.80, 95% CI 0.65-0.97, p = 0.025), and higher cumulative dose of opioids (OR = 10.16, 95% CI 1.25-82.43, p = 0.030) were independently associated with extubation failure while also controlling for post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC), intubation length, and echo results. CONCLUSION Higher cumulative opioid doses were associated with a greater incidence of extubation failure in infants post-Norwood procedure. Therefore, patients with higher cumulative doses of opioids should be more closely evaluated for extubation readiness in this population. Low end-tidal CO2 and low pulse-to-respiratory quotient were also associated with failed extubation. Consideration of the pulse-to-respiratory quotient in the extubation readiness assessment can be beneficial in the Norwood population.
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Affiliation(s)
- Sebastian Acosta
- Department of Pediatrics, Division of Cardiology, Texas Children's Hospital and Baylor College of Medicine, 1102 Bates Ave. Suite 430.01, Houston, Texas, 77030, USA.
| | | | | | | | | | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
- Department of Pediatrics, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Paul Checchia
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Feng Zheng
- Department of Pediatrics, Division of Neonatology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Fabio Savorgnan
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, 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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Loomba RS, Villarreal EG, Flores S, Farias JS, Constas A. The Inadequate Oxygen Delivery Index and Its Correlation with Venous Saturation in the Pediatric Cardiac Intensive Care Unit. Pediatr Cardiol 2023:10.1007/s00246-023-03302-x. [PMID: 37743384 DOI: 10.1007/s00246-023-03302-x] [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: 07/21/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023]
Abstract
Continuous monitoring software, T3, has an integrated index called the inadequate oxygen delivery index 50% (IDO2-50) which displays a probability that the mixed venous saturation is below a user-selected threshold of 30-50%. The primary aim of this study was to determine the correlation of the IDO2-50 with a measured venous saturation. The secondary aim of this study was to characterize the hemodynamic factors that contributed to the IDO2-50. This single-center, retrospective study aimed to characterize the correlation between IDO2-50 and inferior vena cava (IVC) saturation. A Bayesian Pearson correlation was conducted to assess the correlation between the collected variables of interest, with a particular interest in the correlation between the IDO2-50 and the IVC saturation. Receiver operator curve (ROC) analysis to assess the ability of the IDO2-50 to identify when the venous saturation was less than 50%. Bayesian linear regression was done with the IDO2-50 (dependent variable) and other independent variables. A total of 113 datasets were collected across 15 unique patients. IDO2-50 had moderate correlation with the IVC saturation (correlation coefficient - 0.569). The IDO2-50 had a weak but significant correlation with cerebral near-infrared spectroscopy (NIRS) values, a weak but significant correlation with heart rate, and a moderate and significant correlation with arterial saturation. ROC analysis demonstrated that the IDO2-50 had a good ability to identify a venous saturation below 50%, with an area under the curve of 0.797, cutoff point of 24.5 with a sensitivity of 81%, specificity of 66%, positive predictive value of 44%, and negative predictive value of 91%. Bayesian linear regression analysis yielded the following model: 237.82 + (1.18 × age in months) - (3.31 × arterial saturation) - (1.92 × cerebral NIRS) + (0.84 × heart rate). The IDO2 index has moderate correlation with IVC saturation. It has good sensitive and negative predictive value. Cerebral NIRS does appear to correlate better with the underlying venous saturation than the IDO2 index.
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Affiliation(s)
| | - Enrique G Villarreal
- Department of Pediatrics, Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico.
| | - Saul Flores
- Texas Children's Hospital/Baylor School of Medicine, Houston, TX, USA
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Miller AG, Kumar KR, Brown J, Mattin D, Marshburn O, Muddiman J, Allareddy V, Rotta AT. Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease. Respir Care 2023; 68:300-308. [PMID: 36414274 PMCID: PMC10027143 DOI: 10.4187/respcare.10251] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation. METHODS We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively. RESULTS We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation. CONCLUSIONS The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.
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Affiliation(s)
| | - Karan R Kumar
- Duke University Medical Center, Durham, North Carolina
| | - Jessica Brown
- Duke University Medical Center, Durham, North Carolina
| | - Dirk Mattin
- Duke University Medical Center, Durham, North Carolina
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Clark MG, Townsley MM. Extubation Failure After Modified Blalock-Taussig Shunt Placement: Why Does It Occur and How Can It Be Prevented? J Cardiothorac Vasc Anesth 2022; 36:4037-4038. [PMID: 35989240 DOI: 10.1053/j.jvca.2022.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew G Clark
- Division of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Matthew M Townsley
- Division of Congenital Cardiac Anesthesiology, University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL.
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