Extubation failure in pediatric intensive care incidence and outcomes

Etiology and Risk Factors for Extubation Failure in Low Birth Weight Infants Undergoing Congenital Heart Surgery

OBJECTIVE

The aim of the present study was to explore the etiology and risk factors of extubation failure (ExF) in low birth weight (LBW) infants undergoing congenital heart surgery.

DESIGN

Retrospective, comparative study.

SETTING

A Cantonese cardiac center in China.

PARTICIPANTS

The cases of all LBW infants undergoing congenital heart surgery admitted to the authors' neonatal intensive care unit from January 2010 to September 2018 were reviewed retrospectively. ExF was defined as reintubation within 72 hours after extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, preoperative, perioperative, and postoperative data were collected. The exclusion criteria were surgical ligation of patent ductus arteriosus and no extubation attempt. Risk factors for ExF were analyzed with univariate and multivariate logistic regression analysis. Ninety-nine infants met the inclusion criteria; the study comprised 66 males and 33 females, including 60 premature infants. ExF occurred in 16 of 99 infants for various kinds of reasons. Infants with ExF had longer postoperative intensive care unit length of stay (LOS) (p < 0.001) and total hospital LOS (p = 0.022). The multivariate logistic regression analysis identified preoperative mechanical ventilation (odds ratio 9.3; 95% confidence interval 1.11-79.52; p = 0.040) and prolonged mechanical ventilation before the first attempted extubation (odds ratio 6.48; 95% confidence interval 1.20-35.17; p = 0.030) as risk factors for ExF.

CONCLUSIONS

The prevalence of ExF is very high in LBW infants undergoing congenital cardiac surgery. ExF in LBW infants is associated with an increase in hospital LOS. Presumed reasons for failed extubation are diverse. Preoperative mechanical ventilation and prolonged mechanical ventilation before the first attempted extubation were independent risk factors for ExF.

Achieving Sustainability in Reducing Unplanned Extubations in a Pediatric Cardiac ICU

OBJECTIVES

To determine the incidence of unplanned extubations in a pediatric cardiac ICU in order to prove sustainability of our previously implemented quality improvement initiative. Additionally, we sought to identify risk factors associated with unplanned extubations as well as review the overall outcome of this patient population.

DESIGN

Retrospective chart review.

SETTING

Pediatric cardiac ICU at Children's Hospital of Colorado on the Anschutz Medical Center of the University of Colorado.

PATIENTS

Intubated and mechanically ventilated patients in the cardiac ICU from July 2011 to December 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,612 hospitalizations for 2,067 patients were supported with mechanical ventilation. Forty-five patients had 49 episodes of unplanned extubations (four patients > 1 unplanned extubation). The average unplanned extubation rate per 100 ventilator days was 0.4. Patients who had an unplanned extubation were younger (0.09 vs 5.45 mo; p < 0.001), weighed less (unplanned extubation median weight of 3.0 kg [interquartile range, 2.5-4.5 kg] vs control median weight of 6.0 kg [interquartile range, 3.5-13.9 kg]) (p < 0.001), and had a longer length of mechanical ventilation (8 vs 2 d; p < 0.001). Patients who had an unplanned extubation were more likely to require cardiopulmonary resuscitation during their hospital stay (54% vs 18%; p < 0.001) and had a higher likelihood of in-hospital mortality (15% vs 7%; p = 0.001). There was a significant difference in surgical acuity as denoted by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score and patients with an unplanned extubation had a higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (p = 0.019). Contributing factors associated with unplanned extubation were poor endotracheal tube tape integrity, inadequate tube securement, and/or inadequate sedation. A low rate of unplanned extubation was maintained even in the setting of increasing patient complexity and an increase in patient volume.

CONCLUSIONS

A low rate of unplanned extubation is sustainable even in the setting of increased patient volume and acuity. Additionally, early identification of patients at higher risk of unplanned extubation may also contribute to decreasing the incidence of unplanned extubation.

Falha de extubação em unidade de terapia intensiva pediátrica: estudo de coorte retrospectivo

RESUMO Na unidade de terapia intensiva (UTI) pediátrica, a falha de extubação pode aumentar o risco de mortalidade. Este estudo objetivou: (1) verificar a taxa de falha de extubação na UTI pediátrica de um hospital público do município de Bauru (São Paulo, Brasil); (2) identificar a principal causa atribuída à falha de extubação; (3) avaliar se características como a idade e o tempo de ventilação mecânica invasiva (VMI) estão associadas à falha de extubação; (4) avaliar se o tempo de permanência na UTI e hospital é maior entre os pacientes que apresentaram falha de extubação. Foi realizado estudo de coorte retrospectivo com 89 pacientes internados de maio de 2017 até julho de 2018. Os resultados mostraram taxa de falha de extubação correspondente a 16%. A principal causa atribuída à falha de extubação foi o estridor laríngeo, totalizando 57% dos casos. A comparação intergrupos (sucesso vs. falha de extubação) não mostrou diferenças em relação à idade (p=0,294) e ao tempo de VMI (p=0,228). No entanto, observamos que o grupo falha de extubação apresentou maior tempo de UTI (p=0,000) e hospital (p=0,010). Desta forma, concluímos que a taxa de extubação está de acordo com a observada em outros estudos. O estridor laríngeo foi responsável por mais da metade dos casos de falha de extubação. Embora a idade e o tempo de VMI não tenham sido características associadas à falha de extubação, esta contribuiu para o maior período de permanência na UTI e no hospital.

A predictive model for extubation readiness in extremely preterm infants

OBJECTIVE

To develop an estimator for predicting successful extubation for an individual preterm infant.

STUDY DESIGN

This was a retrospective study that included infants with birth weights ≤1250 g, who were admitted to a tertiary NICU over a 7-year period, received mechanical ventilation and had an elective extubation attempt within 60 days of age. Perinatal and periextubation characteristics were compared in the successful and failed extubation groups.

RESULTS

Of 621 screened infants, 312 were included. Extubation succeeded in 73% and failed in 27%. Adjusted factors associated with successful extubation included greater gestational age, chronologic age, pre-extubation pH and lower pre-extubation FiO₂, along with lower "peak" respiratory severity score in the first 6 h of age.

CONCLUSIONS

We used readily available demographic and clinical data to create an extubation readiness estimator that provides the probability of extubation success for an individual preterm infant (http://elasticbeanstalk-us-east-2-676799334712.s3-website.us-east-2.amazonaws.com/).

Spontaneous Breathing Trial for Prediction of Extubation Success in Pediatric Patients Following Congenital Heart Surgery: A Randomized Controlled Trial

OBJECTIVES

To evaluate the usefulness of a spontaneous breathing trial for predicting extubation success in pediatric patients in the postoperative period after cardiac surgery compared with a physician-led weaning.

STUDY DESIGN

Randomized, controlled trial.

SETTING

PICU of a tertiary-care university hospital.

PATIENTS

A population of pediatric patients following cardiac surgery for congenital heart disease.

INTERVENTIONS

Patients on mechanical ventilation for more than 12 hours after surgery who were considered ready for weaning were randomized to the spontaneous breathing trial group or the control group. The spontaneous breathing trial was performed on continuous positive airway pressure with the pressure support of 10 cmH2O, the positive end-expiratory pressure of 5 cmH2O, and the fraction of inspired oxygen less than or equal to 0.5 for 2 hours. Patients in the control group underwent ventilator weaning according to clinical judgment.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was extubation success defined as no need for reintubation within 48 hours after extubation. Secondary outcomes were PICU length of stay, hospital length of stay, occurrence rate of ventilator-associated pneumonia, and mortality. One hundred and ten patients with the median age of 8 months were included in the study: 56 were assigned to the spontaneous breathing trial group and 54 were assigned to the control group. Demographic and clinical data and Risk Adjustment for Congenital Heart Surgery-1 classification were similar in both groups. Patients undergoing the spontaneous breathing trial had greater extubation success (83% vs 68%, p = 0.02) and shorter PICU length of stay (median 85 vs 367 hr, p < 0.0001) compared with the control group, respectively. There was no significant difference between groups in hospital length of stay, occurrence rate of ventilator-associated pneumonia, and mortality.

CONCLUSIONS

Pediatric patients with congenital heart disease undergoing the spontaneous breathing trial postoperatively had greater extubation success and shorter PICU length of stay compared with those weaned according to clinical judgment.

The effect of pressure support on imposed work of breathing during paediatric extubation readiness testing

BACKGROUND

Paediatric critical care practitioners often make use of pressure support (PS) to overcome the perceived imposed work of breathing (WOBimp) during an extubation readiness test (ERT). However, no paediatric data are available that shows the necessity of adding of pressure support during such tests. We sought to measure the WOBimp during an ERT with and without added pressure support and to study its clinical correlate. This was a prospective study in spontaneously breathing ventilated children < 18 years undergoing ERT. Using tracheal manometry, WOBimp was calculated by integrating the difference between positive end-expiratory pressure (PEEP) and tracheal pressure (Ptrach) over the measured expiratory tidal volume (VTe) under two paired conditions: continuous positive airway pressure (CPAP) with and without PS. Patients with post-extubation upper airway obstruction were excluded.

RESULTS

A total of 112 patients were studied. Median PS during the ERT was 10 cmH₂O. WOBimp was significantly higher without PS (median 0.27, IQR 0.20-0.50 J/L) than with added PS (median 0.00, IQR 0.00-0.11 J/L). Although there were statistically significant changes in spontaneous breath rate [32 (23-42) vs. 37 (27-46) breaths/min, p < 0.001] and higher ET-CO₂ [5.90 (5.38-6.65) vs. 6.23 (5.55-6.94) kPa, p < 0.001] and expiratory Vt decreased [7.72 (6.66-8.97) vs. 7.08 (5.82-8.08) mL/kg, p < 0.001] in the absence of PS, these changes appeared clinically irrelevant since the Comfort B score remained unaffected [12 (10-13) vs. 12 (10-13), P = 0.987]. Multivariable analysis showed that changes in WOBimp occurred independent of endotracheal tube size.

CONCLUSIONS

Withholding PS during ERT does not lead to clinically relevant increases in WOBimp, irrespective of endotracheal tube size.

Outcomes of mechanical ventilation according to WIND classification in pediatric patients

Background

The outcomes of weaning processes are not well known in pediatric patients, and the International Conference Classification on weaning from mechanical ventilation showed limited application. We evaluate the relationship between the new Weaning according to a New Definition (WIND) classification and outcome in pediatric patients.

Methods

We conducted a retrospective cohort study in a tertiary pediatric intensive care unit (ICU). We included patients under 18 years of age who received invasive mechanical ventilation for more than 24 h and excluded cases with other than the first ICU admissions, tracheostomy with home ventilation before admission, intubation or weaning processes conducted in other ICU, and weaning with extracorporeal membrane oxygenation. Weaning processes were classified into four groups according to weaning duration after the first separation attempt (SA): no-SA, short weaning (< 24 h), difficult weaning (24 h–7 days), and prolonged weaning (> 7 days). Mortality rates were compared across groups using the Kruskal–Wallis test, and risk factors for the no-SA group were analyzed by multivariate logistic regression tests with age, sex, severity score at admission, admission type, and underlying disease as variables.

Results

Among 313 patients, 224 were enrolled and had a median age of 2.1 (interquartile range 0.5–6.6) years. Spontaneous breathing tests were done in 70.1% of enrolled patients. The median duration of intubation to the first SA was 4 (range 0–36) days, and 92.8% patients underwent the first SA within 14 days. The mortality rate was 0% in the short (0/99) and difficult (0/53) weaning groups and 17.9% (5/28) in the prolonged weaning group (p < 0.001). The mortality rate of the no-SA group was 93.2% (41/44). Admission severity (hazard ratio 1.036, confidence interval 1.022–1.050) and underlying oncologic disease (hazard ratio 7.341, confidence interval 3.008–17.916) were independent risk factors for lack of SA.

Conclusions

In conclusion, WIND classification is associated with ICU mortality in pediatric patients. Further studies of this association are required to improve protocols associated with the weaning process and clinical outcomes.

Trial registration Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0547-2) contains supplementary material, which is available to authorized users.

Near-infrared spectroscopy for prediction of extubation success after neonatal cardiac surgery

INTRODUCTION

Reliable predictors of extubation readiness are needed and may reduce morbidity related to extubation failure. We aimed to examine the relationship between changes in pre-extubation near-infrared spectroscopy measurements from baseline and extubation outcomes after neonatal cardiac surgery.

MATERIALS AND METHODS

In this retrospective cross-sectional multi-centre study, a secondary analysis of prospectively collected data from neonates who underwent cardiac surgery at seven tertiary-care children's hospitals in 2015 was performed. Extubation failure was defined as need for re-intubation within 72 hours of the first planned extubation attempt. Near-infrared spectroscopy measurements obtained before surgery and before extubation in patients who failed extubation were compared to those of patients who extubated successfully using t-tests.

RESULTS

Near-infrared spectroscopy measurements were available for 159 neonates, including 52 with single ventricle physiology. Median age at surgery was 6 days (range: 1-29 days). A total of 15 patients (9.4 %) failed extubation. Baseline cerebral and renal near-infrared spectroscopy measurements were not statistically different between those who were successfully extubated and those who failed, but pre-extubation cerebral and renal values were significantly higher in neonates who extubated successfully. An increase from baseline to time of extubation values in cerebral oximetry saturation by ≥ 5 % had a positive predictive value for extubation success of 98.6 % (95%CI: 91.1-99.8 %).

CONCLUSION

Pre-extubation cerebral near-infrared spectroscopy measurements, when compared to baseline, were significantly associated with extubation outcomes. These findings demonstrate the potential of this tool as a valuable adjunct in assessing extubation readiness after paediatric cardiac surgery and warrant further evaluation in a larger prospective study.

Extubation Failure Rates After Pediatric Cardiac Surgery Vary Across Hospitals

OBJECTIVES

Many hospitals aim to extubate children early after cardiac surgery, yet it remains unclear how this practice associates with extubation failure. We evaluated adjusted extubation failure rates and duration of postoperative mechanical ventilation across hospitals and assessed cardiac ICU organizational factors associated with extubation failure.

DESIGN

Secondary analysis of the Pediatric Cardiac Critical Care Consortium clinical registry.

SETTING

Pediatric Cardiac Critical Care Consortium cardiac ICUs.

PATIENTS

Patients with qualifying index surgical procedures from August 2014 to June 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We modeled hospital-level adjusted extubation failure rates using multivariable logistic regression. A previously validated Pediatric Cardiac Critical Care Consortium model was used to calculate adjusted postoperative mechanical ventilation. Observed-to-expected ratios for both metrics were derived for each hospital to assess performance. Hierarchical logistic regression was used to assess the association between cardiac ICU factors and extubation failure. Overall, 16,052 surgical hospitalizations were analyzed. Predictors of extubation failure (p < 0.05 in final case-mix adjustment model) included younger age, underweight, greater surgical complexity, airway anomaly, chromosomal anomaly/syndrome, longer cardiopulmonary bypass time, and other preoperative comorbidities. Three hospitals were better-than-expected outliers for extubation failure (95% CI around observed-to-expected < 1), and three hospitals were worse-than-expected (95% CI around observed-to-expected > 1). Two hospitals were better-than-expected outliers for both extubation failure and postoperative mechanical ventilation, and three were worse-than-expected for both. No hospital was an outlier in opposite directions. Greater nursing hours per patient day and percent nursing staff with critical care certification were associated with lower odds of extubation failure. Cardiac ICU factors such as fewer inexperienced nurses, greater percent critical care trained attendings, cardiac ICU-dedicated respiratory therapists, and fewer patients per cardiac ICU attending were not associated with lower odds of extubation failure.

CONCLUSIONS

We saw no evidence that hospitals trade higher extubation failure rates for shorter duration of postoperative mechanical ventilation after pediatric cardiac surgery. Increasing specialized cardiac ICU nursing hours per patient day may achieve better extubation outcomes and mitigate the impact of inexperienced nurses.

Factors associated with early extubation of patients after corrective tetralogy of Fallot

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.

Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes

Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.

Risk factors for extubation failure in the intensive care unit

OBJECTIVE

To determine the risk factors for extubation failure in the intensive care unit.

METHODS

The present case-control study was conducted in an intensive care unit. Failed extubations were used as cases, while successful extubations were used as controls. Extubation failure was defined as reintubation being required within the first 48 hours of extubation.

RESULTS

Out of a total of 956 patients who were admitted to the intensive care unit, 826 were subjected to mechanical ventilation (86%). There were 30 failed extubations and 120 successful extubations. The proportion of failed extubations was 5.32%. The risk factors found for failed extubations were a prolonged length of mechanical ventilation of greater than 7 days (OR = 3.84, 95%CI = 1.01 - 14.56, p = 0.04), time in the intensive care unit (OR = 1.04, 95%CI = 1.00 - 1.09, p = 0.03) and the use of sedatives for longer than 5 days (OR = 4.81, 95%CI = 1.28 - 18.02; p = 0.02).

CONCLUSION

Pediatric patients on mechanical ventilation were at greater risk of failed extubation if they spent more time in the intensive care unit and if they were subjected to prolonged mechanical ventilation (longer than 7 days) or greater amounts of sedative use.

Pulmonary Dead Space Fraction and Extubation Success in Children After Cardiac Surgery

OBJECTIVES

1) Determine the correlation between pulmonary dead space fraction and extubation success in postoperative pediatric cardiac patients; and 2) document the natural history of pulmonary dead space fractions, dynamic compliance, and airway resistance during the first 72 hours postoperatively in postoperative pediatric cardiac patients.

DESIGN

A retrospective chart review.

SETTING

Cardiac ICU in a quaternary care free-standing children's hospital.

PATIENTS

Twenty-nine with balanced single ventricle physiology, 61 with two ventricle physiology.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We collected data for all pediatric patients undergoing congenital cardiac surgery over a 14-month period during the first 72 hours postoperatively as well as prior to extubation. Overall, patients with successful extubations had lower preextubation dead space fractions and shorter lengths of stay. Single ventricle patients had higher initial postoperative and preextubation dead space fractions. Two-ventricle physiology patients had higher extubation failure rates if the preextubation dead space fraction was greater than 0.5, whereas single ventricle patients had similar extubation failure rates whether preextubation dead space fractions were less than or equal to 0.5 or greater than 0.5. Additionally, increasing initial dead space fraction values predicted prolonged mechanical ventilation times. Airway resistance and dynamic compliance were similar between those with successful extubations and those who failed.

CONCLUSIONS

Initial postoperative dead space fraction correlates with the length of mechanical ventilation in two ventricle patients but not in single ventricle patients. Lower preextubation dead space fractions are a strong predictor of successful extubation in two ventricle patients after cardiac surgery, but may not be as useful in single ventricle patients.

Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation

Extubation failure is associated with considerable morbidity and mortality in postoperative patients with congenital heart disease (CHD). The study purpose was to investigate initial extubation success utilizing neurally adjusted ventilatory assist (NAVA) compared with pressure-regulated volume controlled, synchronized intermittent mandatory ventilation with pressure support (SIMV-PRVC + PS) for ventilatory weaning in patients who required prolonged mechanical ventilation (MV). Also, total days on MV, inotropes, sedation, analgesia, and pediatric intensive care unit (PICU) length of stay (LOS) between both groups were compared. This was a non-randomized pilot study utilizing historical controls (SIMV-PRVC + PS; n  = 40) compared with a prospective study population (NAVA; n  = 35) in a Level I PICU and was implemented to help future trial designs. All patients ( n  = 75) required prolonged MV ≥96 hours due to their complex postoperative course. Ventilator weaning initiation and management was standardized between both groups. Ninety-seven percent of the NAVA group was successfully extubated on the initial attempt, while 80% were in the SIMV-PRVC + PS group ( p  = 0.0317). Patients placed on NAVA were eight times more likely to have successful initial extubation (odds ratio [OR]: 8.50, 95% confidence interval [CI]: 1.01, 71.82). The NAVA group demonstrated a shorter median duration on MV (9.0 vs. 11.0 days, p  = 0.032), PICU LOS (9.0 vs. 13.5 days, p  < 0.0001), and shorter median duration of days on dopamine (8.0 vs. 11.0 days, p  = 0.0022), milrinone (9.0 vs. 12.0 days, p  = 0.0002), midazolam (8.0 vs. 12.0 days, p  < 0.0001), and fentanyl (9.0 vs. 12.5 days, p  < 0.0001) compared with the SIMV-PRVC + PS group. NAVA compared with SIMV-PRVC + PS was associated with a greater initial extubation success rate. NAVA should be considered as a mechanical ventilator weaning strategy in postoperative congenital heart disease (CHD) patients and warrants further investigation.

Association between oxygenation and ventilation indices with the time on invasive mechanical ventilation in infants

BACKGROUND

Invasive mechanical ventilation (IMV) is a common practice in pediatric intensive care unit (PICU). However, the role of oxygenation (OI) and ventilation (VI) indices regarding the time on IMV has not been fully understood.

BASIC PROCEDURES

The study was conducted with infants up to 24 months of age, hospitalized in PICU for two consecutive years. The values of ventilatory parameters, OI, VI, and blood gas of infants, collected in the first seven days in IMV, were associated with the time on IMV. IMV was classified into: short (≤seven days) and long time (>seven days). The comparison was made from the first to the seventh day. Alpha=0.05.

MAIN FINDINGS

Of 142 infants [mean age=7.51±6.33 months], 59 (41.5%) remained on IMV for a short time and 83 (58.5%) for a long time. Differences in PaO2 values were found on the second day, and PaO2/FiO2 ratio on the second, third and fourth days, with higher values in the short-term IMV. For FiO2 from the second to the fifth day; Pinsp from the first to the seventh day; PEEP from the second to the sixth day; mechanical respiratory frequency from the second to the seventh day, PaCO2 on the second day; Paw from the first to the seventh day, OI from the second to the sixth day, and VI from the first to the seventh day, the values were higher in the long-term IMV.

CONCLUSIONS

The OI and VI can be considered as potential predictors of long-term IMV, along with other markers obtained during the IMV.

Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability

Introduction

Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011.

Methods

The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012-13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line-associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias.

Results

A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3-4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias.

Conclusions

After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3-4 category procedures.

Extubation Failure Is Associated With Increased Mortality Following First Stage Single Ventricle Reconstruction Operation

OBJECTIVES

To identify the prevalence, causes, risk factors, and outcomes associated with extubation failure following first stage single ventricle reconstruction surgery.

DESIGN

Retrospective cohort analysis of neonates who underwent a first stage single ventricle reconstruction operation. Extubation failure was defined as endotracheal reintubation within 48 hours of first extubation attempt.

SETTING

The Royal Children's Hospital, Melbourne.

PATIENTS

Data were collected for all infants who underwent a Norwood or Damus-Kaye-Stansel procedure between 2005 and 2014 at our institution.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Extubation failure occurred in 23 of 137 neonates (16.8%; 95% CI, 11.0-24.1%) who underwent a trial of extubation. Overall, 42 patients (30.7%) were extubated to room air, 88 (64.2%) to nasal continuous positive airway pressure, and seven (5.1%) to high-flow nasal cannulae, though there was no major difference in extubation failure rates between these three groups (p = 0.37). The median time to reintubation was 16.7 hours (interquartile range, 3.2-35.2), and male infants failed extubation more frequently (63.2% vs 87.0%; p = 0.02), although age, gestation, weight, cardiac diagnosis (hypoplastic left heart syndrome vs other single ventricle conditions), shunt type (modified Blalock-Taussig vs right ventricle-pulmonary artery shunt), intraoperative perfusion times, preextubation mechanical ventilation duration, preextubation acid-base status, and postoperative fluid balance were not related to extubation outcome. Infants who failed extubation had a higher intensive care mortality (19.4% vs 3.5%; p = 0.03) and in-hospital mortality (30.4% vs 6.1%; p < 0.001).

CONCLUSIONS

There is a high prevalence of extubation failure following first stage single ventricle reconstruction, and this is associated with considerably worse patient outcomes. The high prevalence and also the wide variation in rates of extubation failure in reported literature provide with an opportunity for implementation of quality assurance activities to minimize this complication and improve outcomes.

An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment

OBJECTIVES

Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist-led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU.

DESIGN

A quality improvement project.

SETTING

Single center, tertiary care Children's Hospital PICU.

PATIENTS

All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016.

INTERVENTIONS

A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation.

MEASUREMENTS AND MAIN RESULTS

We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015-January 2016), compared with 833 patients from the pre-daily spontaneous breathing trial period (February 2013-January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre-daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation.

CONCLUSIONS

An interprofessionally developed respiratory therapist-led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

OBJECTIVES

To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.

STUDY DESIGN

This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 24^0/7 to 27^6/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.

RESULTS

Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).

CONCLUSIONS

Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00233324.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial

OBJECTIVES

To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children.

DESIGN

Double-blind, placebo-controlled randomized clinical trial.

SETTING

PICU in a tertiary referral center.

PATIENTS

Children 1 month to 15 years old who underwent mechanical ventilation.

INTERVENTIONS

Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor.

MEASUREMENTS AND MAIN RESULTS

One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively).

CONCLUSIONS

The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.

Risk Factors for Extubation Failure in Extremely Low Birth Weight Infants

BACKGROUND

Although antenatal steroids and early use nasal continuous positive airway pressure (NCPAP) have significantly improved outcomes of neonatal respiratory distress syndrome, intubation with ventilator support is still commonly required in extremely low birth weight (ELBW) infants. The optimal timing of extubation in ELBW infants remains unclear.

METHODS

We retrospectively analyzed all ELBW preterm infants who were admitted to our neonatal intensive care unit (NICU) from January 2009 to December 2013. Demographic, ventilation, and arterial blood gas analysis results prior to and 2 hours after extubation were collected. Extubation failure was defined as reintubation due to deterioration of respiratory condition within 7 days after extubation. Risk factors for extubation failure were analyzed.

RESULTS

In total, 173 ELBW infants were born and admitted to our NICU during these 5 years. Among these 173 infants, 77 (44.5%) used NCPAP only during their hospitalization (20 diagnosed with chronic lung disease (CLD), 25.9%). Among the 95 patients that required intubation, 27 patients expired so extubation was not attempted. Sixteen of 68 (23.5%) survival cases required reintubation within 7 days after extubation. We found that gestational age, birth body weight, and sex ratio did not differ between the successful extubation group and the failed extubation group. Univariate analysis showed that the failed extubation group had a lower arterial pH right before and 2 hours after extubation, with a lower bicarbonate level after extubation. Further multivariate logistic regression analysis revealed an association between poor acid-base homeostasis 2 hours after extubation (pH < 7.3 and HCO₃ < 18 mM/L) and extubation failure (odds ratio 4.56 and 6.187 and 95% confidence interval: 1.263∼16.462 and 1.68∼22.791, respectively).

CONCLUSION

This study shows that nearly half of ELBW infants do not require intubation. Among ELBW infants who require invasive ventilator support, those who have lower postextubation arterial pH and bicarbonate levels are at high risk of extubation failure.

Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis

OBJECTIVES

To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease.

STUDY DESIGN

We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality.

RESULTS

We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13).

CONCLUSIONS

In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication.

Association Between Deep Sedation from Continuous Intravenous Sedatives and Extubation Failures in Mechanically Ventilated Patients in the Pediatric Intensive Care Unit

OBJECTIVE

The primary objective of this study was to determine whether an association exists between deep sedation from continuous infusion sedatives and extubation failures in mechanically ventilated children. Secondary outcomes evaluated risk factors associated with deep sedation.

METHODS

This was a retrospective cohort study conducted between January 1, 2009, and October 31, 2012, in the pediatric intensive care unit (PICU) at Duke Children's Hospital. Patients were included in the study if they had been admitted to the PICU, had been mechanically ventilated for ≥48 hours, and had received at least one continuous infusion benzodiazepine and/or opioid infusion for ≥24 hours. Patients were separated into 2 groups: those deeply sedated and those not deeply sedated. Deep sedation was defined as having at least one documented State Behavioral Scale (SBS) of -3 or -2 within 72 hours prior to planned extubation.

RESULTS

A total of 108 patients were included in the analysis. Both groups were well matched with regard to baseline characteristics. For the primary outcome, there was no difference in extubation failures in those who were deeply sedated compared to those not deeply sedated (14 patients [22.6%] versus 7 patients [15.2%], respectively; p = 0.33). After adjusting for potential risk factors, patients with a higher weight percentile for age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00-1.03), lower Glasgow Coma Score (GCS) score prior to intubation (OR 0.85; 95% CI 0.74-0.97), and larger maximum benzodiazepine dose (OR 1.93; 95% CI 1.01-3.71) were associated with greater odds of deep sedation. A higher GCS prior to intubation was significantly associated with increased odds of extubation failure (OR 1.19; 95% CI 1.02-1.39).

CONCLUSIONS

While there was no statistically significant difference in extubation failures between the 2 groups included in this study, considering the severe consequences of extubation failure, the numerical difference reported may be clinically important.

Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals

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.

Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk Factors

BACKGROUND

The purpose of this study was to explore the prevalence, etiology, and risk factors of extubation failure (EF) in post-cardiac surgery neonates.

METHODS

Neonates (30 days old or younger) who underwent cardiac surgery and were admitted to the cardiac intensive care unit between September 2010 and February 2016 were included. The prevalence and etiology of EF, defined as reintubation within 48 hours, were reviewed. Demographic, operative, and perioperative data were retrospectively collected. Multiple logistic regression models were constructed to identify the risk factors for EF.

RESULTS

The median age at surgery was 10 days. Extubation failure occurred in 25 of 156 cases (16.0%; 95% confidence interval: 10.6% to 22.7%), because of respiratory dysfunction (n = 16), hemodynamic instability (n = 4), upper airway obstruction (n = 4), or gastrointestinal bleeding (n = 1). Subsequent extubations were successful in 17 cases (68%) because of medical optimization of the causes of reintubation. The remaining 8 cases needed surgical reintervention, including tracheostomy and cardiac surgery. The inhospital mortality rate was 2.6%. In a bivariate analysis, younger age, airway diseases, ventilation before surgery, prolonged mechanical ventilation, and delayed sternal closure were associated with EF. The multivariable analysis identified airway diseases (adjusted odds ratio 18.2, 95% confidence interval: 3.8 to 88.6, p = 0.0003) and mechanical ventilation longer than 7 days (adjusted odds ratio 8.2, 95% confidence interval: 1.9 to 34.9, p = 0.0046) as risk factors for EF.

CONCLUSIONS

The prevalence of EF is relatively high in neonatal cardiac surgery. The etiologies can be diverse. Extubation of neonates at high risk after cardiac surgery, based on these possible risk factors, requires more diligent approaches.

Tracheal extubation in children with difficult airways: a descriptive cohort analysis

BACKGROUND

Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events.

AIMS

The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways.

METHODS

A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥ 3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation.

RESULTS

A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were <10 kg in weight. Of these children, one child required emergency tracheostomy, and two children (one with tracheal stenosis and other with spinal muscular atrophy) suffered from hypoxemic cardiac arrest and anoxic brain damage, respectively, and eventually died.

CONCLUSIONS

In the studied population of children with difficult airways handled in a tertiary center environment, the majority of tracheal extubations could be performed without the use of airway adjuncts. In a minority of patients, tracheal extubation was associated with severe adverse outcomes.

Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants

IMPORTANCE

Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population.

OBJECTIVE

To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation.

DESIGN, SETTING, AND PARTICIPANTS

We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database.

EXPOSURES

The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses.

MAIN OUTCOMES AND MEASURES

The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy.

RESULTS

We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy.

CONCLUSIONS AND RELEVANCE

Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery

OBJECTIVE

Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, although data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population.

DESIGN

Retrospective chart review.

SETTING

Urban tertiary care free-standing children's hospital.

PATIENTS

Neonates (0-30 d) who underwent cardiac surgery at our institution between January 2009 and December 2012 was performed.

INTERVENTIONS

Extubation failure was defined as reintubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure.

MEASUREMENTS AND MAIN RESULTS

We included 120 neonates, of whom 21 (17.5%) experienced extubation failure. On univariate analysis, patients who failed extubation were more likely to have genetic abnormalities (24% vs 6%; p = 0.023), hypoplastic left heart (43% vs 17%; p = 0.009), delayed sternal closure (38% vs 12%; p = 0.004), postoperative infection prior to extubation (38% vs 11%; p = 0.002), and longer duration of mechanical ventilation (median, 142 vs 58 hr; p = 0.009]. On multivariate analysis, genetic abnormalities, hypoplastic left heart, and postoperative infection remained independently associated with extubation failure. Furthermore, patients with infection who failed extubation tended to receive fewer days of antibiotics prior to their first extubation attempt when compared with patients with infection who did not fail extubation (4.9 ± 2.6 vs 7.3 ± 3; p = 0.073).

CONCLUSIONS

Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium

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.

International survey on periextubation practices in extremely preterm infants

OBJECTIVE

To determine periextubation practices in extremely preterm infants (<28 weeks gestation).

DESIGN

A survey consisting of 13 questions related to weaning from mechanical ventilation, assessment of extubation readiness and postextubation respiratory support was developed and sent to clinical directors of level III NICUs in Australia, Canada, Ireland, New Zealand and USA. A descriptive analysis of the results was performed.

RESULTS

112/162 (69%) units responded; 36% reported having a guideline (31%) or written protocol (5%) for ventilator weaning. Extubation readiness was assessed based on ventilatory settings (98%), blood gases (92%) and the presence of clinical stability (86%). Only 54% ensured that infants received caffeine ≤24 h prior to extubation. 16% of units systematically extubated infants on the premise that they passed a Spontaneous Breathing Test with a duration ranging from 3 min (25%) to more than 10 min (35%). Nasal continuous positive airway pressure was the most common type of respiratory support used (84%) followed by nasal intermittent positive pressure ventilation (55%) and high-flow nasal cannula (33%). Reintubation was mainly based on clinical judgement of the responsible physician (88%). There was a lack of consensus on the time frame for definition of extubation failure (EF), the majority proposing a period between 24 and 72 h; 43% believed that EF is an independent risk factor for increased mortality and morbidity.

CONCLUSIONS

Periextubation practices vary considerably; decisions are frequently physician dependent and not evidence based. The definition of EF is variable and well-defined criteria for reintubation are rarely used. High-quality trials are required to inform guidelines and standardise periextubation practices.

Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay

OBJECTIVE

To determine the attributable hospital cost, both operational and departmental, and length of stay associated with unplanned extubations in children admitted to PICU and cardiac ICU.

DESIGN

Retrospective, matched case-control study.

SETTING

Forty-four-bed PICU and 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital.

PATIENTS

Cases with an unplanned extubation were retrospectively identified from July 2011 to March 2013. Controls were PICU and cardiac ICU patients admitted over the same time period and were matched at a ratio of 2:1 for age and diagnosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-eight unplanned extubations were analyzed. There were no differences in patient demographics between the two groups, except the control group had a higher severity of illness as illustrated by a larger Paediatric Index of Mortality II Risk of Mortality. Median total hospital costs were higher in those patients with unplanned extubations as compared with controls ($101,310 vs $64,618; p < 0.001). Patients with an unplanned extubation had longer median ICU length of stay (10 d vs 4.5 d; p < 0.001) and hospital length of stay (16.5 d vs 10 d, p < 0.001).

CONCLUSION

Pediatric patients with unplanned extubations have an associated increase in hospital costs ($36,692/case) and length of stay (6.5 d/case) as compared with age and diagnosis-matched controls. Further efforts are warranted to establish data-driven benchmarks and establishment of unplanned extubations as a critical metric for ICU quality.

Defining sedation-related adverse events in the pediatric intensive care unit

BACKGROUND

Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry.

OBJECTIVES

To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial.

METHODS

In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates.

RESULTS

We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy.

CONCLUSIONS

Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.

Optimizing patient-ventilator synchrony during invasive ventilator assist in children and infants remains a difficult task*

OBJECTIVES

To document and compare the prevalence of asynchrony events during invasive-assisted mechanical ventilation in pressure support mode and in neurally adjusted ventilatory assist in children.

DESIGN

Prospective, randomized, and crossover study.

SETTING

Pediatric and Neonatal Intensive Care Unit, University Hospital of Geneva, Switzerland.

PATIENTS

Intubated and mechanically ventilated children, between 4 weeks and 5 years old.

INTERVENTIONS

Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support, three levels of expiratory trigger setting were compared: expiratory trigger setting as set by the clinician in charge (PSinit), followed by a 10% (in absolute values) increase and decrease of the clinician's expiratory trigger setting. The pressure support session with the least number of asynchrony events was defined as PSbest. Therefore, three periods were compared: PSinit, PSbest, and neurally adjusted ventilatory assist. Asynchrony events, trigger delay, and inspiratory time in excess were quantified for each of them.

MEASUREMENTS AND MAIN RESULTS

Data from 19 children were analyzed. Main asynchrony events during PSinit were autotriggering (3.6 events/min [0.7-8.2]), ineffective efforts (1.2/min [0.6-5]), and premature cycling (3.5/min [1.3-4.9]). Their number was significantly reduced with PSbest: autotriggering 1.6/min (0.2-4.9), ineffective efforts 0.7/min (0-2.6), and premature cycling 2/min (0.1-3.1), p < 0.005 for each comparison. The median asynchrony index (total number of asynchronies/triggered and not triggered breaths ×100) was significantly different between PSinit and PSbest: 37.3% [19-47%] and 29% [24-43%], respectively, p < 0.005). With neurally adjusted ventilatory assist, all types of asynchrony events except double-triggering and inspiratory time in excess were significantly reduced resulting in an asynchrony index of 3.8% (2.4-15%) (p < 0.005 compared to PSbest).

CONCLUSIONS

Asynchrony events are frequent during pressure support in children despite adjusting the cycling off criteria. Neurally adjusted ventilatory assist allowed for an almost ten-fold reduction in asynchrony events. Further studies should determine the clinical impact of these findings.

Prediction of extubation readiness in extreme preterm infants based on measures of cardiorespiratory variability

The majority of extreme preterm infants require endotracheal intubation and mechanical ventilation (ETT-MV) during the first days of life to survive. Unfortunately this therapy is associated with adverse clinical outcomes and consequently, it is desirable to remove ETT-MV as quickly as possible. However, about 25% of extubated infants will fail and require re-intubation which is also associated with a 5-fold increase in mortality and a longer stay in the intensive care unit. Therefore, the ultimate goal is to determine the optimal time for extubation that will minimize the duration of MV and maximize the chances of success. This paper presents a new objective predictor to assist clinicians in making this decision. The predictor uses a modern machine learning method (Support Vector Machines) to determine the combination of measures of cardiorespiratory variability, computed automatically, that best predicts extubation readiness. Our results demonstrate that this predictor accurately classified infants who would fail extubation.

The use of near-infrared spectroscopy during an extubation readiness trial as a predictor of extubation outcome

OBJECTIVES

To determine whether the measurement of cerebral and somatic regional oxygen saturation during an extubation readiness trial predicts extubation failure in postoperative cardiac patients.

DESIGN

Prospective observational study.

SETTING

Tertiary care center cardiac ICU.

PATIENTS

Pediatric patients 1 day to 21 years old following cardiac surgery for congenital heart disease. Patients were included if they were intubated for greater than 12 hours and were undergoing an extubation readiness trial.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data collection included patient demographic, procedural, laboratory, and physiologic variables. Regional oxygen saturation values were recorded using near-infrared spectroscopy at baseline, during a 2-hour extubation readiness trial, and in the first 2 hours postextubation. Ninety-nine extubation readiness trials were conducted in 79 patients. Adjusting for baseline somatic regional oxygen saturation, logistic regression analysis demonstrated that patients with a decline in their minimum somatic regional oxygen saturation of at least 10% during an extubation readiness trial had a 6-time increased odds of extubation failure (p = 0.02; 95% CI, 1.26-29.8). Receiver-operating characteristic curve analysis demonstrated that a 12% decline in the minimum regional oxygen saturation best predicted extubation failure with 54% sensitivity and 82% specificity.

CONCLUSIONS

A 12% decline in somatic regional oxygen saturation during an extubation readiness trial is associated with an increased risk of extubation failure following a successful extubation readiness trial. The addition of somatic regional oxygen saturation measurements to an extubation readiness trial may improve our ability to predict extubation outcome.

Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit?

CONTEXT

There is absence of evidence-based guidelines to determine extubation readiness in the pediatric intensive care unit (PICU).

OBJECTIVE

Evaluate our practice of determining extubation readiness based on physician judgment of preextubation ventilator settings, blood gas analysis, and other factors potentially affecting extubation outcome.

DESIGN

Prospective cohort study from August 2010 to April 2012.

SETTING

Academic, multidisciplinary PICU.

PATIENTS

A total of 319 PICU patients undergoing first planned extubation attempt.

INTERVENTIONS

None.

MEASUREMENTS

Determine the extubation success rate and evaluate factors potentially affecting extubation outcome. The PICU length of stay (LOS) and cost were also recorded. Subgroup analysis was performed based on days of mechanical ventilation (MV).

RESULTS

A total of 319 consecutive patients underwent first planned extubation attempt with a 91% success rate. Factors associated with extubation failure were the length of MV (P < .0001, odds ratio [OR] 2.20); age (P = .02, OR 0.54); preextubation steroids (P = .04, OR 2.40); and postextubation stridor (P < .01, OR 3.40). Ventilator settings and blood gas results had no association with extubation outcome with 1 exception, ventilator rates ≤ 8 were associated with extubation failure in patients with ≤1 day of MV. Extubation failure was associated with prolonged PICU LOS and excess cost, with failures staying 14 days longer (P < .0001) and costing 3.2 time more (P < .0001) than successes.

CONCLUSIONS

Physician judgment to determine extubation readiness led to a first planned extubation success rate of 91%. Age and the length of MV were primary risk factors for failed extubation. In patients with ≤1 day of MV, our findings suggest that confidence in extubation readiness following weaning to low ventilator rates may not be justified. Furthermore, reliance on preextubation ventilator settings and blood gas results to determine extubation readiness may lead to unnecessary prolongation of MV, thereby increasing the PICU LOS and excess cost. These findings are hypothesis generating and require further study for confirmation.

Role of spontaneous breathing trial in predicting successful extubation in premature infants

BACKGROUND

The ability of clinicians to predict successful extubation in mechanically ventilated premature neonates is limited. Identifying objective criteria for predicting successful extubation may reduce the incidence of failed extubation and the duration of mechanical ventilation.

OBJECTIVE

To evaluate the validity of objective measures of lung function and spontaneous breathing trial (SBT) in predicting successful extubation among premature neonates with attempted extubations within the first 3 weeks of life.

METHODS

Respiratory compliance (Crs) along with SBT was performed prior to elective extubations within 3 weeks of age in premature infants ≤ 32 weeks. Extubation was considered successful if patients remained extubated for > 72 hr. Ventilator settings including mean airway pressure (MAP), set rate, and fraction of inspired oxygen (FiO₂) 24 hr after re-intubation were compared with pre-extubation settings, in patients requiring re-intubation.

RESULTS

Thirty-nine of 49 infants (80%) were successfully extubated. Of 41 babies who passed SBT, only 5 infants failed extubation. SBT had 92% sensitivity, 50% specificity, 88% positive predictive, and 63% negative predictive value for successful extubation. Crs was comparable between infants who were successfully extubated and those who were not.

CONCLUSIONS

A SBT prior to extubation may be a practical objective adjunct in predicting successful extubation in ventilated premature infants.

Weaning from mechanical ventilation in paediatrics. State of the art

Weaning from mechanical ventilation is one of the greatest volume and strength issues in evidence-based medicine in critically ill adults. In these patients, weaning protocols and daily interruption of sedation have been implemented, reducing the duration of mechanical ventilation and associated morbidity. In paediatrics, the information reported is less consistent, so that as yet there are no reliable criteria for weaning and extubation in this patient group. Several indices have been developed to predict the outcome of weaning. However, these have failed to replace clinical judgement, although some additional measurements could facilitate this decision.

Prospective evaluation of sedation-related adverse events in pediatric patients ventilated for acute respiratory failure

OBJECTIVES

Sedation-related adverse events in critically ill pediatric patients lack reproducible operational definitions and reference standards. Understanding these adverse events is essential to improving the quality of patient care and for developing prevention strategies in critically ill children. The purpose of this study was to test operational definitions and estimate the rate and site-to-site heterogeneity of sedation-related adverse events.

DESIGN

Prospective cohort study.

SETTING

Twenty-two pediatric intensive care units in the United States enrolling baseline patients into a prerandomization phase of a multicenter trial on sedation management.

PATIENTS

Pediatric patients intubated and mechanically ventilated for acute respiratory failure.

DATA EXTRACTION

Analysis of adverse event data using consistent operational definitions from a Web-based data management system.

MEASUREMENTS AND MAIN RESULTS

There were 594 sedation-related adverse events reported in 308 subjects, for a rate of 1.9 adverse events per subject and 16.6 adverse events per 100 pediatric intensive care unit days. Fifty-four percent of subjects had at least one adverse event. Seven (1%) adverse events were classified as severe, 347 (58%) as moderate, and 240 (40%) as mild. Agitation (30% of subjects, 41% of events) and pain (27% of subjects, 29% of events) were the most frequently reported events. Eight percent of subjects (n = 24) experienced 54 episodes of clinically significant iatrogenic withdrawal. Unplanned endotracheal tube extubation occurred at a rate of 0.82 per 100 ventilator days, and 32 subjects experienced postextubation stridor. Adverse events with moderate intraclass correlation coefficients included: Inadequate sedation management (intraclass correlation coefficient = 0.130), clinically significant iatrogenic withdrawal (intraclass correlation coefficient = 0.088), inadequate pain management (intraclass correlation coefficient = 0.080), and postextubation stridor (intraclass correlation coefficient = 0.078).

CONCLUSIONS

Operational definitions for sedation-related adverse events were consistently applied across multiple pediatric intensive care units. Adverse event rates were different from what has been previously reported in single-center studies. Many adverse events have moderate intraclass correlation coefficients, signaling site-to-site heterogeneity.

Extubation of the difficult airway

Managing the airway in the intensive care unit (ICU) is complicated by a wide array of physiologic factors. Difficult airway may be a consequence of patient’s anatomy or airway edema developed during the ICU stay and mechanical ventilation. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. In this article, we will provide a framework for identifying a difficult airway, criteria for safe extubation, as well as review the devices that are available for airway management in the ICU. Proficiency in identifying a potentially difficult airway and thorough familiarity with strategies and techniques of securing the airway are necessary for safe practice of critical care medicine

Characterization of pediatric patients receiving prolonged mechanical ventilation

OBJECTIVE

To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days.

DESIGN

Prospective cohort.

SETTING

Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina.

PATIENTS

All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine.

CONCLUSIONS

Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.