Non-invasive mechanical ventilation after heart surgery in children

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Cardiopulmonary Management for Severe Aortic Valve Stenosis With Noninvasive Ventilation Using a Nasopharyngeal Tube

The nasopharyngeal tube (NT) is an effective interface for noninvasive ventilation (NIV). In cases of severe heart failure, assistance with noninvasive positive-pressure ventilation (NPPV) effectively reduces afterload and alleviates respiratory effort. We present the case of a three-day-old male neonate diagnosed with severe aortic valve stenosis (AS). In respiratory management, extubation was delayed due to increased respiratory effort and afterload, so this patient was extubated and managed with NPPV using an NT. An uncuffed endotracheal tube was inserted, initiating NIV with a positive end-expiratory pressure of 8 cmH2O. The patient exhibited stable vital signs post-extubation and was weaned off NPPV and transferred to the general ward. In this case of severe AS, the use of NT as an interface for NPPV demonstrated efficacy in respiratory and circulatory management. This approach could have shortened the duration of mechanical ventilation and facilitated safe postoperative care, highlighting the potential benefits of NT in managing severe heart failure.

Noninvasive respiratory support preventing reintubation after pediatric cardiac surgery-A systematic review

OBJECTIVE

To analyze the optimal postextubation respiratory support in pediatric cardiac surgery patients.

DESIGN

Systematic review of randomized controlled trials.

SETTING

Pediatric or neonatal intensive care units.

PARTICIPANTS

All aged children (<16 years) having cardiac surgery and postoperative invasive ventilation.

INTERVENTION

Noninvasive respiratory support, including high flow nasal cannula (HFNC), conventional oxygen therapy (COT), noninvasive positive pressure ventilation (NIPPV), continuous positive pressure (CPAP), and noninvasive high-frequency oscillatory ventilation (NHFOV).

MEASUREMENT AND MAIN RESULTS

Studies were not pooled for statistical synthesis due to the limited number and quality of the included studies. Risk ratios with 95% confidence intervals were calculated for individual studies. A total of 167 studies were screened and six were included. The risk of bias was low in one, high in one, and had some concerns in four of the studies. Extubation failure (defined as reintubation) was the main outcome of interest. Risk ratio for reintubation was 0.10 (CI 0.02-0.40) and 1.07 (CI 0.16-7.26) in HFNC versus COT, 0.49 (CI 0.05-5.28) in HFNC versus NIPPV, 0.40 (CI 0.08-1.94) in HFNOV versus CPAP, 0.75 (CI 0.26-2.18) in HFNOV versus NIPPV, and 1.37 (CI 0.33-5.73) in CPAP versus NIPPV. Treatment durations did not differ between the groups.

CONCLUSION

We did not find clear evidence of a difference in reintubation rates and other clinical outcomes between different noninvasive ventilation strategies. Evidence certainty was assessed to be very low due to the risk of bias, the small number of included studies, and high imprecision. Future quality studies are needed to determine the optimal postextubation support in pediatric cardiac surgery patients.

Risk Factors for Extubation Failure After Pediatric Cardiac Surgery and Impact on Outcomes: A Multicenter Analysis

IMPORTANCE

Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality.

OBJECTIVES

We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF.

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included.

MAIN OUTCOMES AND MEASURES

We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported.

RESULTS

Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality.

CONCLUSION AND RELEVANCE

Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducing EFs.

Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants

BACKGROUND

Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs).

METHODS

We performed a retrospective study of children < 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables.

RESULTS

We studied 51 subjects, median age 44 (interquartile range 0.5-242) d and weight 3.7 (3-4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH < 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24-56] vs 62 [46-72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and FIO2 were higher in subjects who required re-intubation.

CONCLUSIONS

NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO2 , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.

Comparative evaluation of high-flow nasal cannula oxygenation vs nasal intermittent ventilation in postoperative paediatric patients operated for acyanotic congenital cardiac defects

Background

This study aimed to compare high-flow nasal cannula (HFNC) oxygenation vs nasal intermittent ventilation (NIV) oxygenation for respiratory care after extubation in postoperative paediatric cardiac patients.

Methods

This study was a randomised controlled trial. One hundred twenty-one paediatric patients with acyanotic congenital heart disease undergoing corrective cardiac surgery on cardiopulmonary bypass were included in the study. Patients were randomised to receive either HFNC (AIRVO) or NIV (RAM Cannula) postextubation. Arterial blood gas was analysed at different time points perioperatively.

Results

Patients in both the groups were matched with respect to diagnosis and demographic profiles. Baseline hemodynamic and respiratory parameters were also similar in both the groups. Patients in HFNC/AIRVO group did not show improved carbon dioxide (CO2) washout but showed improved pO2 and pO2/FiO2 ratio immediate postextubation. Reintubation rate and other intensive care unit (ICU) complications were similar in both the groups.

Conclusion

Postcardiopulmonary bypass respiratory complications in paediatric patients with congenital acyanotic heart disease can be minimised with newer oxygen therapy devices such as AIRVO (HFNC) or RAM cannula (NIV). In comparison between these two, AIRVO did not show improved CO2 washout over RAM cannula; however, it did provide better oxygenation as measured by pO2 in arterial blood and pO2/FiO2 ratio immediate postextubation. Also, long-term results such as duration of mechanical ventilation and ICU stay were not affected by the choice of device.

Bi-level Positive Airway Pressure Versus Nasal CPAP for the Prevention of Extubation Failure in Infants After Cardiac Surgery

BACKGROUND

Extubation early in the postoperative period is beneficial to the recovery and rehabilitation of patients. This study compared the postoperative extubation failure rates among infants who received postextubation respiratory support by either bi-level positive airway pressure (BPAP) or nasal CPAP following cardiac surgery.

METHODS

This was a single-center randomized controlled trial registered at the Chinese Clinical Trial Registry (number ChiCTR2000041453) and was conducted between January 2020 and March 2021. Ventilated infants who underwent cardiac surgery were randomized to either a BPAP or a nasal CPAP group for ventilatory support following extubation. The primary outcome measure was the extubation failure rate within 48 h.

RESULTS

The analyses included 186 subjects. Treatment failure necessitating re-intubation was noted in 14 of the 93 infants (15%) in the BPAP group and in 11 of the 93 infants (12%) in the nasal CPAP group (P = .52). Moreover, there were no statistically significant differences between the 2 groups regarding the duration of noninvasive ventilation (P = .54), total enteral feeding time (P = .59), or complications (P = .85). We found that both the BPAP group and the nasal CPAP group showed significantly improved oxygenation and relief of respiratory distress after treatment. However, the P_aCO2 level within 24 h was significantly lower in the BPAP group (P = .001) than in the CPAP group. Additionally, the P_aO2 /F_IO2 in the BPAP group was significantly higher than in the nasal CPAP group at 6 h, 12 h, and 24 h after treatment (P < .001).

CONCLUSIONS

The introduction of BPAP for postextubation respiratory support was not inferior to nasal CPAP in infants after cardiac surgery. Moreover, BPAP was shown to be superior to nasal CPAP in improving oxygenation and carbon dioxide clearance.

Ventilation Weaning and Extubation Readiness in Children in Pediatric Intensive Care Unit: A Review

Ventilation is one of the most common procedures in critically ill children admitted to the pediatric intensive care units (PICUs) and is associated with potential severe side effects. The longer the mechanical ventilation, the higher the risk of infections, mortality, morbidity and length of stay. Protocol-based approaches to ventilation weaning could have potential benefit in assisting the physicians in the weaning process but, in pediatrics, clear significant outcome difference related to their use has yet to be shown. Extubation failure occurs in up to 20% of patients in PICU with evidences demonstrating its occurrence related to a worse patient outcome including higher mortality. Various clinical approaches have been described to decide the best timing for extubation which can usually be achieved by performing a spontaneous breathing trial before the extubation. No clear evidence is available over which technique best predicts extubation failure. Within this review we summarize the current strategies of ventilation weaning and extubation readiness evaluation employed in the pediatric setting in order to provide an updated view on the topic to guide intensive care physicians in daily clinical practice. We performed a thorough literature search of main online scientific databases to identify principal studies evaluating different strategies of ventilation weaning and extubation readiness including pediatric patients receiving mechanical ventilation. Various strategies are available in the literature both for ventilation weaning and extubation readiness assessment with unclear clear data supporting the superiority of any approach over the others.

Utilisation of RAM cannula for non-invasive respiratory support for infants in the cardiac ICU

BACKGROUND

Children with CHD carry an additional burden of pulmonary insufficiency, often necessitating prolonged ventilatory support, especially in the peri-operative phase. There has been an increase in the utilisation of non-invasive ventilatory support for these children. The objective of this study was to evaluate the utilisation, safety, and outcomes of RAM cannula as a tool for escalation and de-escalation of respiratory support in paediatric cardiac patients less than one year of age.

METHODS

A single-centre retrospective cohort study of patients supported with RAM cannula.

RESULTS

A total of 275 instances of RAM use were included in the study, 81.1% being post-operative. Patients were stratified into escalation and de-escalation cohorts based on the indication of non-invasive ventilation. The success rate of using RAM cannula was 69.5% overall, 66.1% in the escalation group, and 72.8% in the de-escalation group. At baseline, age at cardiac ICU admission >30 days, FiO2 ≤ 40%, PaCO2 ≤ 50 mmHg; and after 12 hours of non-invasive ventilation support respiratory rate ≤ 60/min, PaO2 ≥ 50 mmHg, PaCO2 ≤ 50 mmHg; and absence of worsening on follow-up chest X-ray predicted the success with a sensitivity of 95% in the logistic regression model. Successful support was associated with a significantly shorter unit stay.

CONCLUSIONS

RAM cannula can be safely used to provide non-invasive support to infants in the cardiac ICU for escalation and de-escalation of respiratory support. Factors associated with success can be used to make decisions about candidacy and appropriate timing of non-invasive ventilation use to maximise effectiveness.

Perioperative Pulmonary Optimization With Average Volume-Assured Pressure Support of a Pediatric Patient With Ullrich Congenital Muscular Dystrophy: A Case Report

Patients with preexisting respiratory compromise are at risk for perioperative respiratory failure. Adult literature has shown benefit with prophylactic postoperative use of noninvasive mechanical ventilation (NIMV). While pediatric literature has documented the increasing use of postoperative NIMV, there is no literature on prophylactic preoperative NIMV in patients with preexisting respiratory compromise. Further, surgical literature does not address preoperative prophylactic use of NIMV, as well as use of the newest modality of NIMV, average volume-assured pressure support (AVAPS). Here, we describe the first report of pre- and postoperative use of AVAPS in a pediatric patient with respiratory compromise from Ullrich disease.

Feasibility of Pediatric Non-Invasive Respiratory Support in Low- and Middle-Income Countries

Non-Invasive respiratory support can be viewed as mechanical respiratory support without endotracheal intubation and it includes continuous positive airway pressure, bi-level positive airway pressure, high flow nasal cannula, and non-invasive positive pressure ventilation. Over past few years, non-invasive respiratory support is getting more popular across pediatric intensive care units for acute respiratory failure as well as for long-term ventilation support at home. It reduces the need for invasive mechanical ventilation, decreases the risk of nosocomial pneumonia as well as mortality in selected pediatric and adult population. Unfortunately, majority of available studies on non-invasive respiratory support have been conducted in high-income countries, which are different from low-and middle-income countries (LMICs) in terms of resources, manpower, and the disease profile. Hence, we need to consider disease profile, severity at hospital presentation, availability of age-appropriate equipment, ability of healthcare professionals to manage patients on non-invasive respiratory support, and cost-benefit ratio. In view of the relatively high cost of equipment, there is a need to innovate to develop indigenous kits/devices with available resources in LMICs to reduce the cost and potentially benefit health system. In this review, we highlight the role of non-invasive respiratory support in different clinical conditions, practical problems encountered in LMICs setting, and few indigenous techniques to provide non-invasive respiratory support.

Early factors related to mortality in children treated with bi-level noninvasive ventilation and CPAP

OBJECTIVE

To describe and analyze the characteristics and the early risk factors for mortality of noninvasive ventilation (NIV) in critically ill children.

STUDY DESIGN

A multicenter, prospective, observational 2-year study carried out with critically ill patients (1 month - 18 years of age) who needed NIV. Clinical data and NIV parameters during the first 12 h of admission were collected. A multilevel mixed-effects logistic regression was performed to identify mortality risk factors.

RESULTS

A total of 781 patients (44.2 ± 57.7 months) were studied (57.8% male). Of them, 53.7% had an underlying condition, and 47.1% needed NIV for lower airway respiratory pathologies. Bi-level NIV was the initial support in 78.2% of the patients. Continuous positive airway pressure (CPAP) was used more in younger patients (33.7%) than in older ones (9.7%; p < .001). About 16.7% had to be intubated and 6.2% died. The risk factors for mortality were immunodeficiency (odds ratio [OR] = 11.79; 95% confidence interval [CI] = 2.95-47.13); cerebral palsy (OR = 5.86; 95% CI = 1.94-17.65); presence of apneas on admission (OR = 5.57; 95% CI = 2.13-14.58); tachypnea 6 h after NIV onset (OR = 2.59; 95% CI = 1.30-6.94); and NIV failure (OR = 6.54; 95% CI = 2.79-15.34).

CONCLUSION

NIV is used with great variability in types of support. Younger children receive CPAP more frequently than older children. Immunodeficiency, cerebral palsy, apneas on admission, tachypnea 6 h after NIV onset, and NIV failure are the early factors associated with mortality.

Perioperative Noninvasive Ventilation After Adult or Pediatric Surgery: A Comprehensive Review

Postoperative pulmonary complications and acute respiratory failure are among the leading causes of adverse postoperative outcomes. Noninvasive ventilation may safely and effectively prevent acute respiratory failure in high-risk patients after cardiothoracic surgery and after abdominal surgery. Moreover, noninvasive ventilation can be used to treat postoperative hypoxemia, particularly after abdominal surgery. Noninvasive ventilation also can be helpful to prevent or manage intraoperative acute respiratory failure during non-general anesthesia, primarily in patients with poor respiratory function. Finally, noninvasive ventilation is superior to standard preoxygenation in delaying desaturation during intubation in morbidly obese and in critically ill hypoxemic patients. The few available studies in children suggest that noninvasive ventilation could be safe and valuable in treating hypoxemic or hypercapnic acute respiratory failure after cardiac surgery; on the other hand, it could be dangerous after tracheoesophageal correction.

Feasibility of Pediatric Non-Invasive Respiratory Support in Low- and Middle-Income Countries

Non-Invasive respiratory support can be viewed as mechanical respiratory support without endotracheal intubation and it includes continuous positive airway pressure, bi-level positive airway pressure, high flow nasal cannula, and non-invasive positive pressure ventilation. Over past few years, non-invasive respiratory support is getting more popular across pediatric intensive care units for acute respiratory failure as well as for long-term ventilation support at home. It reduces the need for invasive mechanical ventilation, decreases the risk of nosocomial pneumonia as well as mortality in selected pediatric and adult population. Unfortunately, majority of available studies on non-invasive respiratory support have been conducted in high-income countries, which are different from low- and middle-income countries (LMICs) in terms of resources, manpower, and the disease profile. Hence, we need to consider disease profile, severity at hospital presentation, availability of age-appropriate equipment, ability of healthcare professionals to manage patients on non-invasive respiratory support, and cost-benefit ratio. In view of the relatively high cost of equipment, there is a need to innovate to develop indigenous kits/ devices with available resources in LMICs to reduce the cost and potentially benefit health system. In this review, we highlight the role of non-invasive respiratory support in different clinical conditions, practical problems encountered in LMICs setting, and few indigenous techniques to provide non-invasive respiratory support.

The final reason paediatric Cardiac ICU patients require care prior to discharge to the floor: a single-centre survey

OBJECTIVE

To determine the Final ICU Need in the 24 hours prior to ICU discharge for children with cardiac disease by utilising a single-centre survey.

METHODS

A cross-sectional survey was utilised to determine Final ICU Need, which was categorised as "Cardiovascular", "Respiratory", "Feeding", "Sedation", "Systems Issue", or "Other" for each encounter. Survey responses were obtained from attending physicians who discharged children (≤18 years of age with ICU length of stay >24 hours) from the Cardiac ICU between April 2016 and July 2018.

MEASUREMENTS AND RESULTS

Survey response rate was 99% (n = 1073), with 667 encounters eligible for analysis. "Cardiovascular" (61%) and "Respiratory" (26%) were the most frequently chosen Final ICU Needs. From a multivariable mixed effects logistic regression model fitted to "Cardiovascular" and "Respiratory", operations with significantly reduced odds of having "Cardiovascular" Final ICU Need included Glenn palliation (p = 0.003), total anomalous pulmonary venous connection repair (p = 0.024), truncus arteriosus repair (p = 0.044), and vascular ring repair (p < 0.001). Short lengths of stay (<7.9 days) had significantly higher odds of "Cardiovascular" Final ICU Need (p < 0.001). "Cardiovascular" and "Respiratory" Final ICU Needs were also associated with provider and ICU discharge season.

CONCLUSIONS

Final ICU Need is a novel metric to identify variations in Cardiac ICU utilisation and clinical trajectories. Final ICU Need was significantly influenced by benchmark operation, length of stay, provider, and season. Future applications of Final ICU Need include targeting quality and research initiatives, calibrating provider and family expectations, and identifying provider-level variability in care processes and mental models.

Use of Noninvasive Ventilation in Respiratory Failure After Extubation During Postoperative Care in Pediatrics

The purpose of this study was to determine the rate of failure of noninvasive ventilation (NIV) after cardiac surgery in pediatric patients with respiratory failure after extubation and to identify predictive success factors. This was a prospective cohort study of pediatric patients diagnosed with congenital heart disease who underwent heart surgery and used NIV. Data were collected from 170 patients with a median age of 2 months. No patient presented cardiorespiratory arrest nor any other complication during the use of NIV. The success rate for the use of NIV was 61.8%. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used Chi-square, Mann-Whitney, and Student's t tests, which were performed after univariate and multivariate logistic regression for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), maximum oxygen saturation (OR 0.88 with p = 0.011), and maximum fraction of inspired oxygen (FiO₂) (OR 1.16 with p < 0.001) influenced NIV failure. The following variables did not present a statistical difference: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 score (p = 0.097), age (p = 0.098), invasive mechanical ventilation duration (p = 0.186), and NIV duration (p = 0.804). In conclusion, NIV can be successfully used in children who, after cardiac surgery, develop respiratory failure in the 48 h following extubation. Although the use of higher pressure gradients and higher FiO₂ are associated with a greater failure rate for NIV use, it was found to be generally safe.

Neonatal intensive care unit patients recovering in the post anesthesia care unit: An observational analysis of postextubation complications

BACKGROUND

Neonatal patients are at higher risk in the perioperative period than older infants and children. Extubation as an early goal for noenatal intensive care unit patients presenting for surgery is undergoing a renaissance period, and an exploration of adverse events following selection for extubation immediately after general anesthesia has not specifically been undertaken in this population.

AIMS

The objective of this study is to determine the adverse events most commonly encountered in neonatal intensive care unit patients recovering from anesthesia in the post anesthesia care unit, quantify the risk of event occurrence, and identify risk factors that may increase the risk of postoperative adverse events.

METHODS

All neonatal intensive care unit patients presenting to the operating room 6/1/2014-5/31/2018 who recovered in the  post anesthesia care unit were included for analysis. Univariate analyses were conducted utilizing the Wilcoxon rank-sum test or Fisher exact test. Due to the low event rate, a small-sample generalized estimating equation model was created with a major event composite as the outcome and explanatory variables with P values < .1 on univariate analysis. Statistically significant continuous variables were then dichotomized based on Youden index.

RESULTS

There were 707 operative cases in 607 patients. There were 81 total events recorded, and 64/81 were considered to be major events; all of which were respiratory. The risk of any postoperative event was 11.5%, major respiratory event requiring intervention by a nurse or provider was 9.1%, and reintubation was 0.8%. Birth weight < 1.58 kg (OR 3.71; 95% CI 2.11-6.53; P < .001) and postmenstrual age at surgery <41 weeks (OR 3.20; 95% CI 1.54-6.63; P < .001) were strongly associated with an increased risk of a major postoperative respiratory event.

CONCLUSION

The most important factors associated with major events in the post anesthesia care unit following extubation of neonatal intensive care unit patients were birth weight < 1.58 kg and postmenstrual age at surgery < 41 weeks. A patient with both features has a 7-fold increase in the odds of a major respiratory event in the post anesthesia care unit. Careful consideration of the postoperative ventilation and monitoring strategy must be given to patients with low birth weight (<1.58 kg) or who are <41 weeks postmenstrual age at the time of surgery.

Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial

BACKGROUND

Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO₂ ] after pediatric laparoscopic surgery.

METHODS

Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO₂ ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events.

RESULTS

At 1 hour postoperatively, mean [(A-a) DO₂ ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO₂ (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO₂ ] and PaO₂ were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups.

CONCLUSIONS

An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.

Comparison of two cardiopulmonary bypass strategies with a miniaturized tubing system: a propensity score-based analysis

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.

Contemporary ventilatory strategies for surgical patients

Respiratory failure affects a significant percentage of critically ill children, necessitating both invasive and non-invasive respiratory support. As the outcomes of these patients have improved, children with higher acuity and more complex respiratory pathophysiology require mechanical ventilation. Despite growing understanding of lung-protective strategies and ventilation induced lung injury, certain patients still require harmful ventilatory settings with conventional mechanical ventilation (CMV). High frequency ventilation, neurally adjusted ventilatory assist, and airway pressure release ventilation offer feasible alternatives to CMV. In addition to minimizing the risk of ventilatory induced lung injury when used appropriately, they provide a unique environment to facilitate operations on certain neonates and older children. Finally, non-invasive ventilation is now commonly employed in children with surgical conditions.

Positive Airway Pressure Versus High-Flow Nasal Cannula for Prevention of Extubation Failure in Infants After Congenital Heart Surgery

OBJECTIVES

Compare the impact of initial extubation to positive airway pressure versus high-flow nasal cannula on postoperative outcomes in neonates and infants after congenital heart surgery.

DESIGN

Retrospective cohort study with propensity-matched analysis.

SETTING

Cardiac ICU within a tertiary care children's hospital.

PATIENTS

Patients less than 6 months old initially extubated to either high-flow nasal cannula or positive airway pressure after cardiac surgery with cardiopulmonary bypass were included (July 2012 to December 2015).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 258 encounters, propensity matching identified 49 pairings of patients extubated to high-flow nasal cannula versus positive airway pressure. Extubation failure was 12% for all screened encounters. After matching, there was no difference in extubation failure rate between groups (positive airway pressure 16% vs high-flow nasal cannula 10%; p = 0.549). However, compared with high-flow nasal cannula, patients initially extubated to positive airway pressure experienced greater resource utilization: longer time to low-flow nasal cannula (83 vs 28 hr; p = 0.006); longer time to room air (159 vs 110 hr; p = 0.013); and longer postsurgical hospital length of stay (22 vs 14 d; p = 0.015).

CONCLUSIONS

In this pediatric cohort, primary extubation to positive airway pressure was not superior to high-flow nasal cannula with respect to prevention of extubation failure after congenital heart surgery. Compared with high-flow nasal cannula, use of positive airway pressure was associated with increased hospital resource utilization. Prospective initiatives aimed at establishing best clinical practice for postoperative noninvasive respiratory support are needed.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

Methods

The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.

Results

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.

Conclusions

These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.