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Abstract
INTRODUCTION Our aim was to present the initial experience with a protocol-driven early extubation strategy and to identify risk factors associated with failed spontaneous breathing trials within 12 hours after surgery. METHODS A single institutional retrospective study of children up to 18 years of age was conducted in post-operative cardiac surgical patients over a 1-year period. A daily spontaneous breathing trial protocol was used to assess patients' readiness for extubation. The study population (n = 129) was stratified into two age groups: infants (n = 84) and children (n = 45), and further stratified according to ventilation time: early extubation (ventilation time less than 12 h, n = 86) and deferred extubation (ventilation time more than 12 h, n = 43). Mann-Whitney U-test and binomial logistic regression were used for statistical analysis. RESULTS Early extubated infants had shorter ICU (4 versus 6 days, p = 0.003) and hospital length of stays (16 versus 19 days, p = 0.006), lower re-intubation rates (1 versus 7 patients, p = 0.003), and lower mortality (0 versus. 4 patients, p = 0.01) than deferred extubated infants. There was no significant difference in the studied outcomes in the children group. Malnourished infants and longer cardiopulmonary bypass times were independently associated with failed spontaneous breathing trials within 12 hours after cardiac surgery. CONCLUSIONS Early extubated infants after cardiac surgery had shorter ICU and hospital length of stay, without an increase in morbidity and mortality, compared to infants who deferred extubation. Nutritional status and longer cardiopulmonary bypass times were risk factors for failed spontaneous breathing trial.
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Martin S, Jackson K, Anton J, Tolpin DA. Pro: Early Extubation (<1 Hour) After Cardiac Surgery Is a Useful, Safe, and Cost-Effective Method in Select Patient Populations. J Cardiothorac Vasc Anesth 2022; 36:1487-1490. [PMID: 35033437 DOI: 10.1053/j.jvca.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Simon Martin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX.
| | - Kirk Jackson
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - James Anton
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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Pan SJ, Frabitore SZ, Ingram AR, Nguyen KN, Adams PS. Transesophageal probe placement increases endotracheal tube cuff pressure but is not associated with postoperative extubation failure after congenital cardiac surgery. Ann Card Anaesth 2020; 23:447-452. [PMID: 33109802 PMCID: PMC7879897 DOI: 10.4103/aca.aca_143_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: The concomitant use of cuffed endotracheal tubes (ETT) and transesophageal echocardiography (TEE) probes increases ETT cuff pressures (CP), which may contribute to mucosal ischemia and perioperative complications such as failed extubation. Aims: To assess changes in ETT CP after TEE insertion in patients of different age groups undergoing congenital heart surgery and examine the relationship between ETT CP and postoperative extubation failure. Settings and Design: Single-center quality improvement project. Subjects and Methods: ETT CP was measured with a manometer following intubation and again after TEE insertion. Tracheal perfusion pressure was then calculated and postoperative extubation failures were recorded. Statistical Analysis: Chi-square testing, Fisher’s-exact testing, one-way analysis of variance testing or Kruskal–Wallis testing with Dunn's pairwise, and student's t-test or Wilcoxon rank-sum testing were used to analyze the data. Results: Median ETT CP increased significantly after TEE insertion in each age group, with infants showing a smaller magnitude of increase (+2 [1-6] cm H2O, P < 0.001) than adults (+12 [8-14] cm H2O, P = 0.008) (intergroup comparison P = 0.002). Five patients (9%) failed extubation, all of which were infants. Within the infant subgroup, no significant difference existed between failed vs successful extubation regarding ETT CP during bypass (15 ± 1 vs 16 ± 2 mmHg, P = 0.206) or tracheal perfusion pressure pre-bypass (34 ± 9 vs 38 ± 11 mmHg, P = 0.518), during bypass (20 ± 9 vs 22 ± 6 mmHg, P = 0.697), or post-bypass (42 ± 9 vs 41 ± 9 mmHg, P = 0.923). There was a significant difference in cardiopulmonary bypass duration (151 ± 29 vs 85 ± 32 min, P < 0.001). Conclusion: Factors beyond intraoperative ETT CP likely play a larger role in postoperative extubation failure.
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Affiliation(s)
- Stephanie J Pan
- Department of Anaesthesiology and Perioperative Medicine, Division of Paediatric Anaesthesiology, University of Pittsburgh School of Medicine, USA
| | - Stephen Z Frabitore
- Department of Anaesthesiology and Perioperative Medicine, Division of Paediatric Anaesthesiology, University of Pittsburgh School of Medicine, USA
| | - Angela R Ingram
- Department of Anaesthesiology and Perioperative Medicine, Division of Paediatric Anaesthesiology, University of Pittsburgh School of Medicine, USA
| | - Khoa N Nguyen
- Department of Anaesthesiology and Perioperative Medicine, Division of Paediatric Anaesthesiology, University of Pittsburgh School of Medicine, USA
| | - Phillip S Adams
- Department of Anaesthesiology and Perioperative Medicine, Division of Paediatric Anaesthesiology, University of Pittsburgh School of Medicine, USA
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Samuel R, Froese N, Betts K, Gandhi S. Intraoperative Extubation Post Arterial Switch Operation for Transposition of the Great Arteries With Intact Ventricular Septum: A One-Year, Single Center Experience. Semin Thorac Cardiovasc Surg 2020; 33:134-140. [PMID: 32621961 DOI: 10.1053/j.semtcvs.2020.06.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/27/2020] [Indexed: 11/11/2022]
Abstract
We sought to examine the clinical impact of intraoperative extubation (IE) in neonates undergoing the arterial switch operation (ASO) for D-transposition of the great arteries with intact ventricular septum (dTGA/IVS). This was a single center retrospective study of patients who underwent ASO for dTGA/IVS in the 12 months after an institutional change in practice favoring IE when clinically feasible. A control group was obtained by identifying the same number of consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. Primary outcome measures included morbidity, mortality, length of hospital and intensive care unit stay and reintubation rates. There were no significant differences in the preoperative and operative characteristics between the 2 groups. Of the 10 patients who underwent ASO for dTGA/IVS in the 12 months post institutional change in practice, all (100%) were extubated intraoperatively and none (0%) required reintubation. The median length of intensive care unit stay was 2 days for both the intraoperative and non-IE groups (mean 2.2 and 3 days respectively). The median length of stay in hospital was 4 days in the IE group and 5.5 days in the non-IE group (mean 4.5 and 6 days respectively). No patients died and there was no significant difference in morbidity between the 2 groups. Our data suggests IE post ASO for dTGA/IVS is safe and displays a statistically insignificant trend toward earlier discharge from hospital.
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Affiliation(s)
- Rosh Samuel
- Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada.
| | - Norbert Froese
- Division of Pediatric Anesthesia, Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, 4500 Oak Street, Vancouver, British Columbia, V6H 3N1, Canada
| | - Kim Betts
- Faculty of Health Science, School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Sanjiv Gandhi
- Division of Pediatric Cardiovascular & Thoracic Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada
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Nasr VG, DiNardo JA. Con: Extubation in the Operating Room After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2542-2544. [PMID: 32362543 DOI: 10.1053/j.jvca.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Fast tracking after repair of congenital heart defects. Indian J Thorac Cardiovasc Surg 2020; 37:183-189. [PMID: 32421036 PMCID: PMC7222923 DOI: 10.1007/s12055-020-00924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/30/2019] [Accepted: 01/02/2020] [Indexed: 11/20/2022] Open
Abstract
Fast tracking after repair of congenital heart defects (CHD) is a process involving the reduction of perioperative period by timely admission, early extubation after surgery, short intensive care unit (ICU) stay, early mobilisation, and faster hospital discharge. It requires a coordinated multidisciplinary team involvement. In the last 2 decades, many centres have adopted the fast tracking strategy in paediatric cardiac population, safely and successfully extubating patients in the OR with reported benefits in terms of reduced morbidity and ICU/hospital stay. In this manuscript, we will review the literature available on early extubation after repair of CHD and share our experience with this approach.
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Garg RK, Thareen JK, Mehmood A, Nakao M, Basappanavar V, Jain R, Sam M, Khan AA, Di Donato RM. Implementation of On-table Extubation After Pediatric Cardiac Surgery in the Developing World. J Cardiothorac Vasc Anesth 2020; 34:2611-2617. [PMID: 32057669 DOI: 10.1053/j.jvca.2019.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
In the recent years there has been increasing trend towards the practice of on-table extubation after pediatric cardiac surgery among practitioner in European and non-European countries. In this article we share our experience with on-table extubation among children after cardiac surgery in the developing world supported with the currently available literature.
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Affiliation(s)
- Rajnish K Garg
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.
| | - Jameel K Thareen
- Cardiac Surgery, Al Qassimi Hospital, Sharjah, United Arab Emirates
| | - Akhter Mehmood
- Pediatric Intensive Care, Dubai Hospital, Dubai, United Arab Emirates
| | - Masakazu Nakao
- Cardiac Surgery Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Vikram Basappanavar
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Richie Jain
- Departments of Cardiac Anesthesia, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Monsy Sam
- Clinical Perfusion, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Abdul Ahad Khan
- Clinical Perfusion, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Roberto M Di Donato
- Cardiac Surgery Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
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Vener DF. Another Way to Skin a Cat (Apologies to the SPCA and PETA). World J Pediatr Congenit Heart Surg 2018; 9:537-538. [PMID: 30157744 DOI: 10.1177/2150135118782898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David F Vener
- 1 Pediatric Cardiovascular Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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