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

Results

A total of 416 patients less than 1 year old were included in this review. This cohort included 234 patients (56%) who underwent tracheal extubation in the OR, of who 25 subsequently required reintubation (11%), either immediately or following admission to the CTICU. The 209 patients who remained extubated comprised a wide spectrum of cases, with the majority of them being ventricular septal repairs (45 patients: 21%), followed by Tetralogy of Fallot repairs (30 patients: 14%), stage 1 hybrid procedure (24 patients: 12%), atrioventricular canal repairs (17 patients: 8%), and bidirectional Glenn (14 patients: 7%). The remaining 182 patients (44%) returned to the CTICU intubated, with 27 (15%) requiring reintubation following a trial of tracheal extubation. The difference in the proportion of failed extubations between patients first extubated in the OR and patients first extubated in the CTICU was not statistically significant (chi-square p = 0.204). Patients requiring reintubation were distinguished from patients successfully extubated (in the OR or CTICU) by lower body weight (reintubated median, 4.3 vs 4.9 kg; p < 0.001) and greater STAT score (reintubated median, 1.7 vs 0.8; p < 0.001). Median LOS was significantly longer among patients requiring reintubation (29 vs 14 d; p < 0.001), and there were 14 of 52 in-hospital deaths (27%) among reintubated patients, compared to 12 of 364 (3%) among successfully extubated patients (p < 0.001).

Table 1 compares patient characteristics by extubation timing (OR vs CTICU) and success among 319 patients who had CPB. Greater LOS and in-hospital mortality were observed among patients requiring reintubation whether the initial extubation was attempted in the OR or in the CTICU. Associations between reintubation and elevated STAT and RACHS scores, as well as prolonged CPB time, were observed only among patients initially extubated in the OR. In Table 2, similar comparisons are reported for 97 patients who did not undergo CPB. As above, this table demonstrates prolonged LOS and greater in-hospital mortality following failed extubation, whether in the OR or CTICU. Elevated STAT and RACHS scores were correlated with failed extubation in the OR, but not in the CTICU.

Weight less than 3.6 kg and CPB time more than 80 minutes were shown to predict failed extubation in our past experience,[5] and we used the present data to compute extubation success rates for patients meeting one or both of these criteria. For nine patients with both risk factors, the success rate of early tracheal extubation was 89%. Patients weighing less than 3.6 kg had good success (33/44; 86%) with early (OR) tracheal extubation, while prolonged CPB time (> 80 min) was more of an obstacle to successful early extubation, with success demonstrated in 31 of 47 patients (66%) in the CPB group who were extubated in the OR.

The consequences of reintubation for in-hospital mortality were further investigated using survival analysis of 407 patients who survived at least 1 day after tracheal extubation. A log-rank test confirmed statistically significant difference in survival from extubation until discharge by the need for reintubation (p = 0.006). Kaplan-Meier curves stratified by extubation timing (in the OR vs in the CTICU) and need for reintubation are presented in Figure 2. The log-rank tests assessed separately for early and late extubation indicate that in-hospital mortality was correlated with reintubation among patients extubated in the CTICU (n = 173; p = 0.018) but not among patients extubated in the OR (n = 234; p = 0.098).

Figure 2.

Kaplan-Meier curves depicting extubation timing, reintubation, and mortality. CTICU = cardiothoracic ICU, OR = operating room.

Table 3 further describes the patients who required reintubation (groups 2 and 4), dividing them into groups according to the time elapsed from the initial tracheal extubation until reintubation. Following extubation in the OR, five patients were reintubated within 4 hours, 16 patients were reintubated in 4–24 hours, and four patients were reintubated in more than 24 hours; among patients extubated in the CTICU, six were reintubated within 4 hours, 12 were reintubated in 4–24 hours, and nine were reintubated in more than 24 hours. The overall difference in time to reintubation (categorized as above) was not statistically significant when combining CPB and non-CPB patients (p = 0.285) or when analyzing CPB and non-CPB patients separately (Table 3).

To identify intraoperative factors possibly contributing to reintubation within 24 hours, we identified 22 patients who were extubated in the OR but required reintubation (group 2) within less than 24 hours, and compared intraoperative data from those patients against data from patients with similar characteristics (diagnosis, procedure, STAT, and RACHS scores) in the other three groups. The reintubated patients were similar to the comparison group in age, weight, CPB time, aortic cross-clamp time, last operative arterial blood gas analysis and temperature on arrival to the CTICU. Furthermore, for each of the 22 infants who failed the early tracheal extubation strategy within the first 24 hours (seven within < 4 hr and 15 between 4 and 24 hr), we examined their entire inpatient record, seeking the reason for reintubation and any preceding events (Table 4). Ten of the 22 patients (45%) had agitation that led to an escalation of their pain management regimen, resulting in sedation that ultimately led to respiratory depression and reintubation. Of the remaining 12 cases, 4 (18%) were reintubated for bleeding, 3 (14%) for junctional ectopic tachycardia, 1 (5%) for stridor with increased work of breathing and hypoxemia, 1 (5%) for immediate respiratory failure upon tracheal extubation in the OR, and 1 (5%) for cardiogenic shock.

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