Clinical and hemodynamic factors associated with the outcome of early extubation attempts after right heart bypass surgery

Abstract

Fast-track anesthesia with early extubation (EE) is playing an increasingly important role in pediatric cardiac surgery. We examined the pre- and intra-operative factors contributing to successful EE, and outcomes after right heart bypass surgery (RHB). We retrospectively reviewed the medical records of 71 consecutive children (median age=14 months) admitted over a 4-year period to the pediatric intensive care unit (PICU) of our university-based hospital, after RHB. We compared the characteristics and outcomes of 38 children (54%) extubated <3 h, with those of 33 (46%) extubated >or=3 h after surgery. Odd ratios (OR) and 95% confidence intervals (CI) were calculated. Variables associated with EE included a lower dose of intra-operative fentanyl (OR: 0.95; 95% CI, 0.92-0.99; P=0.03), nitroglycerin (OR: 0.23; 95% CI, 0.07-0.73; P=0.01), and a lower inotropic score (OR: 0.76; 95% CI, 0.61-0.94; P=0.01) on admission. EE was correlated with fewer postoperative respiratory complications (OR: 0.09; 95% CI, 0.02-0.57; P=0.01) and shorter stay in the PICU (OR: 0.88; 95% CI, 0.76-1.03; P=0.12). Our data suggest that EE after RHB could be facilitated in patients with a preserved cardiac function and lower pulmonary vascular resistance. EE could be followed by fewer postoperative pulmonary complications.

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection

“…Kurihara et al retrospectively compared early extubated patients (<3 h) with late extubated ones (≥3 h) after BDG and TCPC; 54% patients were extubated early. [5] The early extubated patients had lower pre-operative mPAP, mean PVR and mean CVP whereas the late extubated patients (>3 h) had poor pre-and post-operative cardiac functions and higher PVR. Decreased cardiac functions, high PVR and the need for large doses of inotropes and vasodilators are the factors that can delay extubation.…”

“…[3][4][5] Although these studies showed that reducing the duration of artificial ventilation by early extubation could minimize potential detrimental effects of positive pressure ventilation, [3][4][5] it is important to know the effect of different ventilation modes used during the weaning period after BDG and TCPC on organ perfusion. Walsh et al noted that ventilation with airway pressure (AWP) release ventilation improves pulmonary blood flow compared…”

“…[2][3][4][5] Lofland reported early extubation in 50 consecutive patients undergoing either BDG or completion Fontan. [3] In their study, after resumption of spontaneous respiration and extubation, mPAP decreased and cardiac index increased.…”

“…Decreased cardiac functions, high PVR and the need for large doses of inotropes and vasodilators are the factors that can delay extubation. [5] In patients having hemorrhagic diathesis, marginally raised mPAP and PVR, right ventricular dominant single ventricle physiology, AV valve insufficiency and/or requiring long aortic cross-clamp time because of additional intracardiac repair, early extubation is usually not feasible. For this group of patients, longer respiratory support is required due to borderline hemodynamics.…”

“…[1] Recently, several reports have addressed the significance of early spontaneous ventilation and early extubation after BDG and total-cavopulmonary shunt (TCPC). [2][3][4][5] These with pressure control ventilation in children after tetralogy of Fallot repair and cavopulmonary shunt operations. [6] Walsh et al hypothesize that shorter the duration of the intrathoracic pressure application, better the pulmonary blood flow.…”