Learning From Experience

Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery

Peter D. Winch, MD, MBA; Anna M. Staudt, MD; Roby Sebastian, MD; Marco Corridore, MD; Dmitry Tumin, PhD; Janet Simsic, MD; Mark Galantowicz, MD; Aymen Naguib, MD; Joseph D. Tobias, MD

Disclosures

Pediatr Crit Care Med. 2016;17(7):630-637. 

In This Article

Abstract and Introduction

Abstract

Objectives: The many advantages of early tracheal extubation following congenital cardiac surgery in young infants and children are now widely recognized. Benefits include avoiding the morbidity associated with prolonged intubation and the consequences of sedation and positive pressure ventilation in the setting of altered cardiopulmonary physiology. Our practice of tracheal extubation of young infants in the operating room following cardiac surgery has evolved and new challenges in the arena of postoperative sedation and pain management have appeared.

Design: Review our institutional outcomes associated with early tracheal extubation following congenital cardiac surgery.

Patients: Inclusion criteria included all children less than 1 year old who underwent congenital cardiac surgery between October 1, 2010, and October 24, 2013.

Measurements and Main Results: A total of 416 patients less than 1 year old were included. Of the 416 patients, 234 underwent tracheal extubation in the operating room (56%) with 25 requiring reintubation (10.7%), either immediately or following admission to the cardiothoracic ICU. Of the 25 patients extubated in the operating room who required reintubation, 22 failed within 24 hours of cardiothoracic ICU admission; 10 failures were directly related to narcotic doses that resulted in respiratory depression.

Conclusions: As a result of this review, we have instituted changes in our cardiothoracic ICU postoperative care plans. We have developed a neonatal delirium score, and have adopted the "Kangaroo Care" approach that was first popularized in neonatal ICUs. This provision allows for the early parental holding of infants following admission to the cardiothoracic ICU and allows for appropriately selected parents to sleep in the same beds alongside their postoperative children.

Introduction

The many advantages of early tracheal extubation following congenital cardiac surgery even in young infants and children are now widely recognized. Such benefits include not only avoiding the morbidity associated with prolonged intubation, but also the consequences of sedation and the effects of positive pressure ventilation in the setting of altered cardiopulmonary physiology. Authors have published review articles on the topic of early tracheal extubation, others have published based on their institutional experience, and others have editorialized on the theoretical advantages or disadvantages of such an approach.[1–4]

In 2009, we published a article detailing predictors of successful early tracheal extubation following congenital cardiac surgery in neonates and infants.[5] Based on a retrospective review of 391 patients less than 1 year old who underwent cardiopulmonary bypass (CPB) and surgery, we attempted to elicit which variables impacted successful early tracheal extubation. We defined such early extubation as occurring in the operating room (OR) immediately following skin closure. After analyzing a number of variables, we developed formulas that predicted the probability of successful tracheal extubation. The most significant variables identified in that analysis included patient weight, CPB time, and serum lactate concentrations (for patients between the ages of 0–3 mo).

As our practice of achieving tracheal extubation in young infants in the OR following cardiac surgery has continued to evolve, new challenges in the arena of postoperative sedation and pain management have appeared. In attempting to address these issues through the administration of sedative and analgesic agents, a certain number of patients have required reintubation following admission to the cardiothoracic ICU (CTICU). We reviewed recent data to assess our experience and understand the reasons for these failures. Specifically, we wanted to understand if there were patients on the anticipated early tracheal extubation pathway that failed based on our published predictors. Furthermore, we wanted to evaluate the factors that led to and the consequences of early tracheal extubation failure, especially in regards to prolonged hospital course and in-hospital mortality.

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