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Maddali MM, Al-Mamari AH, Raju S, Sathiya PM. Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:193-201. [PMID: 37981790 DOI: 10.1177/21501351231204325] [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: 11/21/2023]
Abstract
BACKGROUND The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. METHODS In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. RESULTS A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. CONCLUSIONS Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.
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Affiliation(s)
- Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | | | - Sowmiya Raju
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
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Parody Cuerda G, Jiménez Del Valle JR, Fernández López AR, Barquero Aroca JM. Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:259-268. [PMID: 37150440 DOI: 10.1016/j.redare.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/16/2021] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.
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Affiliation(s)
- G Parody Cuerda
- Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen Macarena, Sevilla, Spain.
| | - J R Jiménez Del Valle
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - A R Fernández López
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J M Barquero Aroca
- Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Saengsin K, Sittiwangkul R, Borisuthipandit T, Trongtrakul K, Tanasombatkul K, Phanacharoensawad T, Moonsawat G, Phinyo P. Predictive factors of extubation failure in pediatric cardiac intensive care unit: A single-center retrospective study from Thailand. Front Pediatr 2023; 11:1156263. [PMID: 37138565 PMCID: PMC10149922 DOI: 10.3389/fped.2023.1156263] [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: 02/01/2023] [Accepted: 03/28/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction/objective Extubation failure increases morbidity and mortality in pediatric cardiac patients, a unique population including those with congenital heart disease or acquired heart disease. This study aimed to evaluate the predictive factors of extubation failure in pediatric cardiac patients and to determine the association between extubation failure and clinical outcomes. Methods We conducted a retrospective study in the pediatric cardiac intensive care unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, from July 2016 to June 2021. Extubation failure was defined as the re-insertion of the endotracheal tube within 48 hours after extubation. Multivariable log-binomial regression with generalized estimating equations (GEE) was performed to explore the predictive factors associated with extubation failure. Results We collected 318 extubation events from 246 patients. Of these, 35 (11%) events were extubation failures. In physiologic cyanosis, the extubation failure group had significantly higher SpO2 than the extubation success group (P < 0.001). The predictive factors associated with extubation failure included a history of pneumonia before extubation (RR 3.09, 95% CI 1.54-6.23, P = 0.002), stridor after extubation (RR 2.57, 95% CI 1.44-4.56, P = 0.001), history of re-intubation (RR 2.24, 95% CI 1.21-4.12, P = 0.009), and palliative surgery (RR 1.87, 95% CI 1.02-3.43, P = 0.043). Conclusion Extubation failure was identified in 11% of extubation attempts in pediatric cardiac patients. The extubation failure was associated with a longer duration of PCICU stay but not with mortality. Patients with a history of pneumonia before extubation, history of re-intubation, post-operative palliative surgery, and post-extubation stridor should receive careful consideration before extubation and close monitoring afterward. Additionally, patients with physiologic cyanosis may require balanced circulation via regulated SpO2.
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Affiliation(s)
- Kwannapas Saengsin
- Division of Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rekwan Sittiwangkul
- Division of Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thirasak Borisuthipandit
- Division of Pulmonology and Critical Care, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Konlawij Trongtrakul
- Division of Pulmonary, Critical Care Medicine, and Allergy Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Krittai Tanasombatkul
- Center for Clinical Epidemiology and Clinical Statistics, Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Correspondence: Phichayut Phinyo
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Gil D, Aljiffry A, Dryer R, Rao N, Figueroa J, Downey L, Shaw FR, Beshish AG. Extubation delays and the associated prostaglandin and opiate dose following coarctation of the aorta repair. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bianchi P, Constantine A, Costola G, Mele S, Shore D, Dimopoulos K, Aw T. Ultra-Fast-Track Extubation in Adult Congenital Heart Surgery. J Am Heart Assoc 2021; 10:e020201. [PMID: 33998289 PMCID: PMC8483528 DOI: 10.1161/jaha.120.020201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/07/2021] [Indexed: 11/16/2022]
Abstract
Background In pediatric cardiac surgery, perioperative management has evolved from slow weaning of mechanical ventilation in the intensive care unit to "ultra-fast-track" anesthesia with early extubation (EE) in theater to promote a faster recovery. The strategy of EE has not been assessed in adults with congenital heart disease, a growing population of patients who often require surgery. Methods And Results Data were collected retrospectively on all patients >16 years of age who underwent adult congenital heart surgery in our tertiary center between December 2012 and January 2020. Coarsened exact matching was performed for relevant baseline variables. Overall, 711 procedures were performed: 133 (18.7%) patients underwent EE and 578 (81.3%) patients received conventional extubation. After matching, patients who received EE required less inotropic or vasopressor support in the early postoperative period (median Vasoactive-inotropic score 0.5 [0.0-2.0] versus 2.0 [0.0-3.5]; P<0.0001) and had a lower total net fluid balance than patients after conventional extubation (1168±723 versus 847±733 mL; P=0.0002). The overall reintubation rate was low at 0.3%. EE was associated with a significantly shorter postoperative length of stay in higher dependency care units before a "step-down" to ward-based care (48 [45-50] versus 50 [47-69] hours; P=0.004). Lower combined intensive care unit and high dependency unit costs were incurred by patients who received EE compared with patients who received conventional extubation (£3949 [3430-4222] versus £4166 [3893-5603]; P<0.0001). Conclusions In adult patients undergoing surgery for congenital heart disease, EE is associated with a reduced need for postoperative hemodynamic support, a shorter intensive care unit stay, and lower health-care-related costs.
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Affiliation(s)
- Paolo Bianchi
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Division of Anaesthetics, Pain Medicine and Intensive CareDepartment of Surgery and CancerImperial College LondonLondonUnited Kingdom
| | - Andrew Constantine
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Giulia Costola
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Sara Mele
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Darryl Shore
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Tuan‐Chen Aw
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
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Winch PD, Mpody C, Murray-Torres TM, Rudolph S, Tobias JD, Nafiu OO. Unplanned Postoperative Reintubation in Children with Bronchial Asthma. J Pediatr Intensive Care 2021; 11:287-293. [DOI: 10.1055/s-0041-1724097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022] Open
Abstract
AbstractUnplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.
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Affiliation(s)
- Peter D. Winch
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Teresa M. Murray-Torres
- Department of Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Shannon Rudolph
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Medical Student Research Program, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
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El Said Saber H, Mousa S, AbouRezk A, Zaglool A. Recovery profile of sugammadex versus neostigmine in pediatric patients undergoing cardiac catheterization: A randomized double-blind study. Anesth Essays Res 2021; 15:272-278. [PMID: 35320954 PMCID: PMC8936865 DOI: 10.4103/aer.aer_139_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Sugammadex is a selective reversal agent which has the ability to reverse deep neuromuscular blockade. However, there are still controversial results as regard sugammadex effects on the quality of recovery. We hypothesized that Sugammadex may have better recovery profile compared to neostigmine in pediatric patients with congenital heart diseases undergoing cardiac catheterization. Patients and Methods: This prospective randomized double-blind study included 50 pediatric patients aged <2 years who were divided into two groups according to the reversal agent used; Group S (Sugammadex) and Group N (Neostigmine). Both groups received the same anesthetic technique during cardiac catheterization, and basic hemodynamic monitoring was ensured in both groups. After the procedure, reversal was done using 4 mg.kg‒1 sugammadex or 0.04 mg. kg‒1 neostigmine plus 0.02 mg. kg‒1 atropine according to the group allocation. Recovery time and side effects were recorded. Results: The two groups showed comparable findings regarding demographics. Nonetheless, the total time of anesthesia had mean values of 91.06 and 101.25 min in the two groups, respectively (P = 0.003), while recovery time had mean values of 1.61 and 9.23 min in the same groups, respectively (P < 0.001). Hemodynamic profile (heart rate and mean arterial pressure) was better after reversal with sugammadex. Blood sugar levels and side effects showed no significant difference between both groups. Conclusion: Sugammadex can be a more rapid and effective alternative to neostigmine for reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing cardiac catheterization.
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Wu K, Chen F, Wang Y, Ti Y, Liu H, Wang P, Ding Y. The Experience of Early Extubation After Paediatric Congenital Heart Surgery in a Chinese Hospital. Heart Lung Circ 2020; 29:e238-e244. [DOI: 10.1016/j.hlc.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 11/29/2022]
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Macaire P, Ho N, Nguyen V, Phan Van H, Dinh Nguyen Thien K, Bringuier S, Capdevila X. Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2020; 45:805-812. [DOI: 10.1136/rapm-2020-101496] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 01/15/2023]
Abstract
BackgroundPostoperative pain after pediatric cardiac surgery is usually treated with intravenous opioids. Recently, the focus has been on postoperative regional analgesia with the introduction of ultrasound-guided erector spinae plane blocks (ESPBs). We hypothesized that bilateral ESPB with a programmed intermittent bolus (PIB) regimen decreases postoperative morphine consumption at 48 hours and improves analgesia in children who undergo cardiac surgery.MethodsThis randomized, double-blind, placebo-controlled study comprised 50 children who underwent cardiac surgery through midline sternotomy. The patients were allocated randomly into two groups: ultrasound-guided bilateral ESPB at the level of T3–T4 transverse process then PIB with saline infusion (group 1, n=23) or PIB with 0.2% ropivacaine (group 2, n=27). Intravenous morphine at 30 µg/kg/hour was used as rescue analgesia. Postoperative pain was assessed using the COMFORT-B score for extubation, drain removal, and mobilization, and the FLACC (Face, Legs, Activity, Cry, Consolability) scale at 0, 2, 4, 6, 8, 12, 16, 20, 24, 36, and 48 hours after surgery. Adverse events were noted.ResultsThe total dose of morphine in 48 hours was significantly decreased in patients receiving a bilateral ESPB with ropivacaine (120±320 µg/kg) compared with patients with saline infusion (512±560 µg/kg; p=0.03). Fourteen per cent of patients required rescue analgesia with morphine in group 2 compared with 41% in group 1 (p=0.05). The patients in group 2 demonstrated significantly reduced COMFORT-B scores at extubation, drain removal, and mobilization compared with those in group 1 and had reduced FLACC scale levels at 20 and 24 hours postoperatively (p=0.05 and p=0.001, respectively). No differences were reported for extubation and drain removal times or for length of hospital stay. In addition, vomiting episodes were decreased in group 2 (p=0.01).ConclusionsIn pediatric cardiac surgery, the results of this study confirm our hypothesis that bilateral ESPB analgesia with ropivacaine decreases the postoperative morphine consumption at 48 hours and demonstrates better postoperative analgesia compared with a control group.Trial registration numberNCT03593642.
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Abstract
BACKGROUND Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. METHODS This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. RESULTS Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). CONCLUSIONS Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.
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Sharma VK, Kumar G, Joshi S, Tiwari N, Kumar V, Ramamurthy HR. An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques. Ann Pediatr Cardiol 2019; 13:31-37. [PMID: 32030033 PMCID: PMC6979031 DOI: 10.4103/apc.apc_36_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 11/17/2022] Open
Abstract
Background: The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management. Aims and Objectives: The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery. Materials and Methods: Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test. Results: A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K. Conclusion: Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.
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Affiliation(s)
- Vipul K Sharma
- Department of Cardio-Thoracic Anaesthesia, Army Hospital Research and Referral, New Delhi, India
| | - Gaurav Kumar
- Department of Cardio-Thoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Saajan Joshi
- Department of Cardio-Thoracic Anaesthesia, Army Hospital Research and Referral, New Delhi, India
| | - Nikhil Tiwari
- Department of Cardio-Thoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Vivek Kumar
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
| | - H Ravi Ramamurthy
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
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Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study. Pediatr Crit Care Med 2019; 20:931-939. [PMID: 31169762 PMCID: PMC6776694 DOI: 10.1097/pcc.0000000000002005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING Five children's hospitals. PATIENTS A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
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Zhang C, Meng B, Wu K, Ding Y. Comparison of two cardiopulmonary bypass strategies with a miniaturized tubing system: a propensity score-based analysis. Perfusion 2019; 34:460-466. [PMID: 30739569 DOI: 10.1177/0267659118825395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The existing cardiopulmonary bypass tubing system has already been significantly improved in our hospital by reducing the priming volume; thus, we further employed a new cardiopulmonary bypass strategy in children based on a miniaturized cardiopulmonary bypass circuit. We aimed to compare the effectiveness of new and conventional strategies by analyzing the outcomes after congenital heart surgery. METHODS We performed a database analysis of all patients undergoing congenital heart surgery with cardiopulmonary bypass at Shenzhen Children's Hospital from 1 May 2015 to 30 June 2017. Propensity score matching was used to adjust for significant covariates, and multivariable regression models and stratified analysis were used to assess the association of cardiopulmonary bypass strategy with outcomes. RESULTS Of 925 total patients, 55.35% were in the conventional strategy group and 44.65% were in the new strategy group. After propensity score matching, there were 610 patients in total, with 305 patients in each group. In the multivariable regression models, the cardiopulmonary bypass strategy was not significantly associated with successful early extubation (p > 0.05), reintubation (p > 0.05), or nasal continuous positive airway pressure (p > 0.05) rates. The new strategy group had fewer hospital stays (p = 0.04) and intensive care unit stays (p < 0.05) compared with patients who underwent conventional strategy. The difference remained statistically significant (p < 0.05) when The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category was <3. CONCLUSION The implementation of a new cardiopulmonary bypass strategy, with selective ultrafiltration based on a miniaturized cardiopulmonary bypass circuit system, was safe and effective for children who underwent congenital heart surgery in a Chinese hospital. The new cardiopulmonary bypass strategy was associated with fewer hospital and intensive care unit stays.
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Affiliation(s)
- Cheng Zhang
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Baoying Meng
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Keye Wu
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yiqun Ding
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
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Akhtar MI, Momeni M, Szekely A, Hamid M, El Tahan MR, Rex S. Multicenter International Survey on the Clinical Practice of Ultra-Fast-Track Anesthesia with On-Table Extubation in Pediatric Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:406-415. [DOI: 10.1053/j.jvca.2018.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/12/2022]
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15
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Iezzi F, Di Summa M, Sarto PD, Munene J. Fast track extubation in paediatric cardiothoracic surgery in developing countries. Pan Afr Med J 2019; 32:55. [PMID: 31143360 PMCID: PMC6522167 DOI: 10.11604/pamj.2019.32.55.14019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/28/2018] [Indexed: 11/11/2022] Open
Abstract
In recent years, low-dose, short-acting anesthetic agents, which replaced the former high-dose opioid regimens, offer a faster postoperative recovery and decrease the need for mechanical ventilatory support. In this study, the aim was to determine the success rate of fast-track approach in surgical procedures for congenital heart disease. There is some evidence, mostly from retrospective analyses, that fast tracking can be beneficial. Ninety-one cases with moderate complex cardiac malformations were operated with fast-track protocol during cardiothoracic charitable missions. The essential aspects of early extubation in our cohort included: selected patients with good preoperative status, good surgical result with hemodynamic stability in low dose of inotropic drugs at the end of bypass, no active bleeding. In this setting a carefull choice and dosing of anesthetic agents, alongside a good postoperative analgesia are mandatory. The authors found that an early extubation (< 4 hours) can be both effective and safe as it reduces intubation and ventilator times without increasing post-operative complications in pediatric congenital heart disease. This study supports a wider use of fast-track extubation protocols in paediatric patients submitted for congenital cardiac surgery in developing countries.
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Affiliation(s)
- Federica Iezzi
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero, Universitaria, Ospedali Riuniti Ancona "Umberto I, GM, Lancisi, G.Salesi," Ancona, Italy
| | - Michele Di Summa
- Department of Cardiothoracic and Vascular Surgery, Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya
| | - Paolo Del Sarto
- Department of Anesthesia and Critical Care, Heart hospital "G. Pasquinucci," Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - James Munene
- Department of Cardiothoracic and Vascular Surgery, Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya
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Chaparro H, Abeldaño-Zuñiga RA. Factors associated with early extubation of patients after corrective tetralogy of Fallot. ENFERMERIA INTENSIVA 2018; 30:154-162. [PMID: 30509876 DOI: 10.1016/j.enfi.2018.08.002] [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: 03/15/2018] [Revised: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. METHODS A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. RESULTS 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26). CONCLUSIONS Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.
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Affiliation(s)
- H Chaparro
- Hospital de Pediatría SAMIC, Juan P. Garrahan, Buenos Aires, Argentina
| | - R A Abeldaño-Zuñiga
- División de Estudios de Posgrado, Universidad de la Sierra Sur, Oaxaca, México.
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Janai AR, Bellinghausen W, Turton E, Bevilacqua C, Zakhary W, Kostelka M, Bakhtiary F, Hambsch J, Daehnert I, Loeffelbein F, Ender J. Retrospective study of complete atrioventricular canal defects: Anesthetic and perioperative challenges. Ann Card Anaesth 2018; 21:15-21. [PMID: 29336386 PMCID: PMC5791481 DOI: 10.4103/aca.aca_110_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The objective of this study was to highlight anesthetic and perioperative management and the outcomes of infants with complete atrioventricular (AV) canal defects. Design: This retrospective descriptive study included children who underwent staged and primary biventricular repair for complete AV canal defects from 1999 to 2013. Setting: A single-center study at a university affiliated heart center. Participants: One hundred and fifty-seven patients with a mean age at surgery of 125 ± 56.9 days were included in the study. About 63.6% of them were diagnosed as Down syndrome. Mean body weight at surgery was 5.6 ± 6.3 kg. Methods: Primary and staged biventricular repair of complete AV canal defects. Measurements and main results: A predefined protocol including timing of surgery, management of induction and maintenance of anesthesia, cardiopulmonary bypass, and perioperative intensive care treatment was used throughout the study. Demographic data as well as intraoperative and perioperative Intensive Care Unit (ICU) data, such as length of stay in ICU, total duration of ventilation including reintubations, and total length of stay in hospital and in hospital mortality, were collected from the clinical information system. Pulmonary hypertension was noted in 60% of patients from which 30% needed nitric oxide therapy. Nearly 2.5% of patients needed permanent pacemaker implantation. Thorax was closed secondarily in 7% of patients. In 3.8% of patients, reoperations due to residual defects were undertaken. Duration of hospital stay was 14.5 ± 4.7 days. The in-hospital mortality was 0%. Conclusion: Protocolized perioperative management leads to excellent outcome in AV canal defect repair surgery.
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Affiliation(s)
- Aniruddha Ramesh Janai
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Wilfried Bellinghausen
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Edwin Turton
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Carmine Bevilacqua
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Waseem Zakhary
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - Martin Kostelka
- Department of Clinic for Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Farhad Bakhtiary
- Department of Clinic for Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Joerg Hambsch
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Ingo Daehnert
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Florian Loeffelbein
- Department of Clinic for Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
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Subramaniam K, DeAndrade DS, Mandell DR, Althouse AD, Manmohan R, Esper SA, Varga JM, Badhwar V. Predictors of operating room extubation in adult cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1656-1665.e2. [DOI: 10.1016/j.jtcvs.2017.05.107] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 05/11/2017] [Accepted: 05/30/2017] [Indexed: 01/26/2023]
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Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals. J Thorac Cardiovasc Surg 2017; 153:1519-1526. [PMID: 28259455 DOI: 10.1016/j.jtcvs.2016.12.042] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/20/2016] [Accepted: 12/30/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. METHODS We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. RESULTS The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18% had major extracardiac anomalies, and 74% underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95% confidence interval, 1.4-6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). CONCLUSIONS This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.
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Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days. PROGRESS IN PEDIATRIC CARDIOLOGY 2016; 45:63-68. [PMID: 28713211 DOI: 10.1016/j.ppedcard.2016.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.
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Joshi RK, Aggarwal N, Agarwal M, Dinand V, Joshi R. Assessment of Risk Factors for a Sustainable “On-Table Extubation” Program in Pediatric Congenital Cardiac Surgery: 5-Year Experience. J Cardiothorac Vasc Anesth 2016; 30:1530-1538. [DOI: 10.1053/j.jvca.2016.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/11/2022]
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Predictors of Early Extubation After Pediatric Cardiac Surgery: A Single-Center Prospective Observational Study. Pediatr Cardiol 2016; 37:1241-9. [PMID: 27272692 DOI: 10.1007/s00246-016-1423-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
This prospective, observational, single-center study aimed to determine the perioperative predictors of early extubation (<24 h after cardiac surgery) in a cohort of children undergoing cardiac surgery. Children aged between 1 month and 18 years who were consecutively admitted to pediatric intensive care unit after cardiac surgery for congenital heart disease between January 2012 and June 2014. Ninety-nine patients were qualified for inclusion during the study period. The median duration of mechanical ventilation was 20 h (range 1-480), and 64 patients were extubated within 24 h. Four of them failed the initial attempt at extubation, and the success rate of early extubation was 60.6 %. Older patient age (p = .009), greater body weight (p = .009), absence of preoperative pulmonary hypertension (p = .044), lower RACHS-1 category (OR, 3.8; 95 % CI 1.35-10.7; p < .05), shorter cardiopulmonary bypass (p = .008) and cross-clamp (p = .022) times, lower PRISM III-24 (p < .05) and PELOD (p < .05) scores, lower inotropic score (p < .05) and vasoactive-inotropic score (p < .05), and lower number of organ failures (OR, 2.26; 95 % CI 1.30-3.92; p < .05) were associated with early extubation. Our study establishes that early extubation can be accomplished within the first 24 h after surgery in low- to medium-risk pediatric cardiac surgery patients, especially in older ones undergoing low-complexity procedures. A large prospective multiple institution trial is necessary to identify the predictors and benefits of early extubation and to facilitate defined guidelines for early extubation.
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Mahle WT, Jacobs JP, Jacobs ML, Kim S, Kirshbom PM, Pasquali SK, Austin EH, Kanter KR, Nicolson SC, Hill KD. Early Extubation After Repair of Tetralogy of Fallot and the Fontan Procedure: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2016; 102:850-858. [DOI: 10.1016/j.athoracsur.2016.03.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
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Winch PD, Staudt AM, Sebastian R, Corridore M, Tumin D, Simsic J, Galantowicz M, Naguib A, Tobias JD. Learning From Experience: Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery. Pediatr Crit Care Med 2016; 17:630-7. [PMID: 27167006 DOI: 10.1097/pcc.0000000000000789] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The many advantages of early tracheal extubation following congenital cardiac surgery in young infants and children are now widely recognized. Benefits include avoiding the morbidity associated with prolonged intubation and the consequences of sedation and positive pressure ventilation in the setting of altered cardiopulmonary physiology. Our practice of tracheal extubation of young infants in the operating room following cardiac surgery has evolved and new challenges in the arena of postoperative sedation and pain management have appeared. DESIGN Review our institutional outcomes associated with early tracheal extubation following congenital cardiac surgery. PATIENTS Inclusion criteria included all children less than 1 year old who underwent congenital cardiac surgery between October 1, 2010, and October 24, 2013. MEASUREMENTS AND MAIN RESULTS A total of 416 patients less than 1 year old were included. Of the 416 patients, 234 underwent tracheal extubation in the operating room (56%) with 25 requiring reintubation (10.7%), either immediately or following admission to the cardiothoracic ICU. Of the 25 patients extubated in the operating room who required reintubation, 22 failed within 24 hours of cardiothoracic ICU admission; 10 failures were directly related to narcotic doses that resulted in respiratory depression. CONCLUSIONS As a result of this review, we have instituted changes in our cardiothoracic ICU postoperative care plans. We have developed a neonatal delirium score, and have adopted the "Kangaroo Care" approach that was first popularized in neonatal ICUs. This provision allows for the early parental holding of infants following admission to the cardiothoracic ICU and allows for appropriately selected parents to sleep in the same beds alongside their postoperative children.
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Affiliation(s)
- Peter D Winch
- 1Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Ohio State University, Columbus, OH. 2Department of Anesthesiology and Perioperative Medicine, Kosair Children's Hospital, University of Louisville School of Medicine, Louisville, KY. 3Department of Pediatrics and Critical Care, Nationwide Children's Hospital, Columbus, OH. 4Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Ohio State University, Columbus, OH
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Gaies M, Tabbutt S, Schwartz SM, Bird GL, Alten JA, Shekerdemian LS, Klugman D, Thiagarajan RR, Gaynor JW, Jacobs JP, Nicolson SC, Donohue JE, Yu S, Pasquali SK, Cooper DS. Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium. Pediatr Crit Care Med 2015; 16:837-45. [PMID: 26218260 PMCID: PMC4672991 DOI: 10.1097/pcc.0000000000000498] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [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
OBJECTIVE To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. DESIGN Retrospective cohort study using prospectively collected clinical registry data. SETTING Pediatric Cardiac Critical Care Consortium registry. PATIENTS All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). CONCLUSIONS Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.
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Affiliation(s)
- Michael Gaies
- 1Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI. 2Department of Pediatrics, Benioff Children's Hospital and University of California San Francisco School of Medicine, San Francisco, CA. 3Department of Critical Care Medicine and Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, ON, Canada. 4Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Cardiac Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 5Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL. 6Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. 7Department of Critical Care Medicine and Cardiology, Children's National Medical Center, Washington, DC. 8Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA. 9Division of Pediatric Cardiac Surgery, Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 10Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 11Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 12Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 13Michigan Congenital Heart Outcomes Research and Discovery Unit, University of Michigan Congenital Heart Center, Ann Arbor, MI. 14The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Abstract
PURPOSE OF REVIEW The focus of postoperative care in the pediatric patient with congenital heart disease has become a reduction in length of stay and morbidity. This review will discuss strategies to achieve this goal and recent studies to support current practices. RECENT FINDINGS Most agree that prolongation of the length of stay following a cardiac surgery contributes to morbidity. Postoperative feeding difficulty, hyperglycemia, acute kidney injury, fluid overload, and prolonged intubation contribute significantly to length of stay. SUMMARY Postoperative care of the neonate and child following a cardiac surgery remains challenging with limited data to drive our practices. Patients remain at risk for significant morbidity, and future studies should focus on recognizing predictors of morbidity, prevention, and treatment.
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Hoda M, Haque A, Aijaz F, Akhtar MI, Rehmat A, Amanullah M, Hasan BS. On-table Extubation after Open Heart Surgery in Children: An Experience from a Tertiary Care Hospital in a Developing Country. CONGENIT HEART DIS 2015; 11:58-62. [DOI: 10.1111/chd.12277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Mehar Hoda
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | - Anwarul Haque
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | - Fareena Aijaz
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
| | | | - Amina Rehmat
- Department of Nursing; Aga Khan University Hospital; Sindh Pakistan
| | - Muneer Amanullah
- Department of Surgery; Aga Khan University Hospital; Sindh Pakistan
| | - Babar S. Hasan
- Department of Pediatrics; Aga Khan University Hospital; Sindh Pakistan
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