Early extubation after pediatric heart surgery: the future?

The Complex Interplay of Variables in Extubation Decision-Making Following Pediatric Cardiac Surgery: A Narrative Review

Pediatric cardiac surgery poses significant challenges in developing countries, where a considerable number of children require intervention for congenital heart disease (CHD). The utilization of endotracheal intubation and anesthesia is pivotal in conducting surgical or angiography procedures on patients with CHD exhibiting diverse anatomical and hemodynamic characteristics. The decision to extubate pediatric patients following cardiac surgery remains a crucial element of postoperative care. This article explores the complexities surrounding extubation decision-making in this population, emphasizing the critical role of surgical, physiological, and postoperative factors. Various preoperative and intraoperative factors influence the timing of extubation. Early extubation is increasingly prevalent, offering benefits like reduced length of stay and minimized drug exposure. Multidisciplinary collaboration and protocol-driven strategies contribute to improved extubation outcomes, emphasizing the need for a comprehensive approach in pediatric cardiac surgery. Future research can focus on the implementation and efficacy of standardized extubation procedures involving collaboration among healthcare experts.

Assessment of the factors that affect fast-track or early extubation following pediatric cardiac surgery

Background

This study aims to evaluate the early extubation rate and the factors affecting early extubation in pediatric patients undergoing cardiac surgery.

Methods

Between August 1st, 2020 and December 1st, 2021, a total of 528 pediatric patients (264 males, 264 females; median age: 4 months; range, 2 days to 24 months) who were followed in the pediatric cardiac intensive care unit after congenital heart surgery were retrospectively analyzed. Demographic and clinical characteristics of the patients including operation and intensive care data were obtained from the medical records. Patients included in the study were categorized into three groups as the group of patients who were extubated in the operating room (fast-track extubation), the group of patients who were extubated in the first 6 h of the operation (early extubation), the group of patients who were extubated after the postoperative 6 h or the group of patients who were not extubated or died (delayed extubation).

Results

Sixty-eight (12.9%) cases had fast-tract extubation, 124 (23.6%) cases had early extubation, and 335 (63.6%) cases had delayed extubation. The median age of the patients in the delayed extubation group was three months, which was significantly lower than those of the other groups (p<0.05). Reintubation rates were 1.5% in the fast-tract extubation group, 2.5% in early extubation group, and 9% in delayed extubation group (p<0.05). The median intensive care unit stay was 3, 5, and 10 days, respectively (p<0.05). Length of hospitalization was significantly higher in the delayed extubation group compared to the other groups (p<0.05). Neonatal age group, Risk Adjustment for Congenital Heart Surgery 1 score >4, Society of Thoracic Surgeons- European Association for Cardio-Thoracic Surgery mortality category >3, cardiopulmonary bypass time >100/min, vasoactive inotrope score >8, acute kidney injury >2, and low weight were found to be independent risk factors for delayed extubation.

Conclusion

Fast-track and early extubation can be successfully applied with low reintubation rates in selected cases with congenital heart surgery. Age, body weight, presence of genetic syndrome, operational risk category, and procedure time may affect the extubation time.

Three-year experience with immediate extubation in pediatric patients after congenital cardiac surgery

Background

In pediatric cardiac anesthesiology, there is increased focus on minimizing morbidity, ensuring optimal functional status, and using health care resources sparingly. One aspect of care that has potential to affect all of the above is postoperative mechanical ventilation. Historically, postoperative ventilation was considered a must for maintaining patient stability. Ironically, it is recognized that mechanical ventilation may increase risk of adverse outcomes in the postoperative period. Hence, many institutions have advocated for immediate extubation or early extubation after many congenital heart surgeries which was first reported decades ago.

Methods

637 consecutive patient charts were reviewed for pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Patients were placed into three groups. Those that were extubated in the operating room (OR) at the conclusion of surgery (Immediate Extubation or IE), those that were extubated within six hours of admission to the ICU (Early Extubation or EE) and those that were extubated sometime after six hours (Delayed Extubation or DE). Multiple variables were then recorded to see which factors correlated with successful Immediate or Early Extubation.

Results

Overall, 338 patients (53.1%) had IE), 273 (42.8%) had DE while only 26 patients (4.1%) had EE. The median age was 1174 days for the IE patients, 39 days for the DE patients, whereas 194 days for EE patients (p < 0.001). Weight and length were also significantly different in at least one extubation group from the other two (p < 0.001). The median ICU LOS was 3 and 4 days for IE and EE patients respectively, whereas it was 9.5 days for DE patients (p < 0.001). DE group had a significant longer median anesthesia time and cardiopulmonary bypass time than the other two extubation groups (p > 63,826.88 < 0.001). Regional low flow perfusion, deep hypothermia, deep hypothermic circulatory arrest, redo sternotomy, use of other sedatives, furosemide, epinephrine, vasopressin, open chest, cardiopulmonary support, pulmonary edema, syndrome, as well as difficult intubation were significantly associated with delayed extubation (IE, EE or DE).

Conclusions

Immediate and early extubation was significantly associated with several factors, including patient age and size, duration of CPB, use of certain anesthetic drugs, and the amount of blood loss and blood replacement. IE can be successfully accomplished in a majority of pediatric patients undergoing surgery for congenital heart disease, including in a minority of infants.