Influence of Early Extubation Location on Outcomes Following Pediatric Cardiac Surgery

Enhanced Recovery after Surgery (ERAS) in Pediatric Cardiac Surgery: Status Quo of Implementation in Europe

OBJECTIVES

Enhanced recovery after surgery (ERAS) is a multimodal care pathway to enhance recovery after surgery that is well established in various surgical disciplines. In pediatric cardiac surgery, implementation of ERAS protocols remains inconsistent. We conducted a survey of active European pediatric cardiac surgical centers to assess the current state of ERAS concepts and the current practice in perioperative pediatric cardiac care.

DESIGN

Prospective, 79-item, web-based cross-sectional survey.

SETTING

Web-based survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care.

PARTICIPANTS

Anesthesiologists of European pediatric cardiac surgical centers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of a total of 98 centers, 50 responded. Eight responses were excluded due to incomplete survey forms or non-European location, leaving 42 responses (42.9%) for statistical analysis. Sixteen of the 42 centers (38.1%) follow an ERAS concept. Only 3 (7.1%) have formalized and detailed the ERAS concept in a written document, covering the entire perioperative period, while 13 (31%) have formalized it solely for the intraoperative period. Regarding regional and local anesthesia, 13 (31%) centers regularly practice regional anesthesia blocks, and 11 (26.2%) centers use wound infiltration by the surgical team.

CONCLUSION

This European survey revealed that implementation of ERAS concepts in pediatric cardiac surgery is generally low, with considerable heterogeneity in clinical practice regarding the timing of extubation, the choice of surgical procedures triggering on-table extubation, the choice of anesthetic drugs and the use of regional anesthesia. More coordinated efforts are needed to implement ERAS concepts in pediatric cardiac surgery and harvest the benefits of ERAS concepts for the pediatric cardiac population.

Early Extubation in Children after Cardiac Surgery. Initial Experience from a Tertiary Care Hospital in Mexico City

Early extubation (EE) in pediatric cardiac surgery has demonstrated important benefits. However, ventilating them for 24 hours or more (delayed decannulation, DD) is an enduring practice. The objectives of this study were to describe the clinical profiles of EE in our setting and analyze its impact and the factors that prolong mechanical ventilation. Children operated on for cardiac surgery from 2016 to 2017 were included. Data were obtained from an electronic database. Comparisons were performed with Pearson's chi-square test, Student's t -test, or Mann-Whitney U test. Multivariate logistic regression was used to evaluate factors associated with DD. Of 649 cases, 530 were extubated on one occasion. EE was performed in 305 children (57.5%): 97 (31.8%) in the operating room and 208 (68.2%) in the intensive care unit (ICU). Reintubation (RI) occurred in 7.5% with EE and 16.9% with DD ( p  = 0.001). Fewer complications and ventilation time and decreased ICU and hospital length of stay resulted with EE. Age, presurgical ventilation, emergency surgery, pump time, attempts to weaning from cardiopulmonary bypass, bleeding greater than usual, and CPR in surgery were associated with DD. EE in the National Institute of Cardiology (INC; Spanish acronym) is in the middle category and has shown benefits without compromising the patient; the fear of further complications, RI, or death is unfounded. Although not all children at the INC can be decannulated early, if there are no or minimal risk factors, it should be a priority.

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.

Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery

BACKGROUND

The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group.

METHODS

In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient.

RESULTS

A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation.

CONCLUSIONS

Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023

Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.

Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes

OBJECTIVES

The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU).

DESIGN

Registry data (August 2014 to October 2020).

SETTING

Forty-five Pediatric Cardiac Critical Care Consortium hospitals.

PATIENTS

Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains.

CONCLUSIONS

UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.

Impact of Extubation Time on Feeding Outcomes after Neonatal Cardiac Surgery: A Single-Center Study

This study aimed to examine the impact of timing of extubation on feeding outcomes in neonates after surgery for congenital heart disease. This was a single-center retrospective study between December 2014 and June 2020. Patients were divided into three categories: extubated in the OR (immediate), extubated in the intensive care unit (ICU) between 0 and 3 days post-procedure (early), and extubated >3 days post-procedure (delayed). Comparing the immediate and early groups, we found no difference in time to first enteral feed (1.3 days (1.0–3.4) vs. 2.3 days (1.1–3.3), p = 0.27). There was no difference in time to first oral feed (2.0 days (1.1–4.5) vs. 3.1 days (1.8–4.4), p = 0.34) and time to goal feed (6.0 days (3.2–8.3) vs. 6.9 days (5.0–9.0), p = 0.15)). There was no difference in all oral feeds at one year: 88% vs. 98%, p = 0.16. The delayed extubation group performed significantly worse on all measures. Immediate and early extubation displayed no differences in feeding outcomes and length of stay in this study, while delayed extubation performed worse on all measures. Thus, we believe that clinicians should emphasize extubation within 3 days post-surgery to improve feeding outcomes while minimizing time hospitalized.

Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in Clinical Outcomes: A Virtual PICU Database Study

OBJECTIVES

Mechanical ventilation is often used in children after cardiac surgery but can impair hemodynamics and cause lung injury. Early extubation may improve ICU length of stay and survival. We aimed to describe trends in early extubation rates and evaluate if centers that more commonly practice early extubation have better severity-adjusted outcomes.

DESIGN

Retrospective analysis was performed of admissions in the Virtual Pediatric Systems (VPS, LLC) database from 2009 to 2018. Early extubation was defined as patients extubated in the operating room or within 6 hours of PICU admission.

SETTING

PICUs participating in the VPS database.

PATIENTS

Children in the VPS database who underwent cardiac surgery.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Among 69,739 subjects, 20% were neonates, 47% underwent early extubation, 5.3% failed extubation, and 2.5% died. Overall, early extubation rates did not change over the study period. Centers were placed in one of four groups based on their early extubation rate in lower complexity surgeries. Centers that most commonly used early extubation had more ICU-free time among all patients in univariable analysis (lowest early extubation group, 23.8 d [interquartile range, 18.2-25.9 d]; highest early extubation group, 24.7 d [20.0-26.2 d]; p < 0.001). After adjusting for center volume, sex, age, surgical complexity, and preoperative ICU admission, increasing center-level early extubation rates were not associated with more ICU-free days. Higher center-level early extubation rate was not associated with mortality in univariable or multivariable analysis but was associated with decreased extubation failure rate (lowest early extubation group, 6.4%; highest early extubation group, 3.6%; p < 0.001).

CONCLUSIONS

In this large, multicenter database study, early extubation rates in postoperative cardiac patients did not significantly change between 2009 and 2018. Centers that performed early extubation more frequently did not have shorter ICU stays or difference in mortality rates but did have lower reintubation rates.