Extubation in the operating room after congenital heart surgery in children

Mittnacht, Alexander J.C.; Thanjan, Maria T; Srivastava, Shubhika; Joashi, Umesh; Bodian, Carol; Hossain, Sabera; Kin, Nobuhide; Hollinger, Ingrid; Nguyen, Khanh

doi:10.1016/j.jtcvs.2007.11.042

Cited by 106 publications

(129 citation statements)

References 23 publications

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“…Following the report from Barash and colleagues 1) in 1980, Vricella and colleagues 6) reported in 2000 that of 201 congenital openheart surgery cases, 175 (87.1%) were extubated in the OR while 188 (93.6%) were extubated within four hours of the operation. In 2008, Mittnacht and colleagues 3) reported that OR extubation was successful in 79% of their pediatric patients (178/224), even in cases where complex procedures were involved. They concluded that the greatest risk factors were young age and a longer duration of CPB.…”

Section: Discussionmentioning

confidence: 99%

“…1,3,14) A long CPB time was consistently associated with prolonged mechanical ventilation and serious bleeding after open-heart surgery. In addition, this was associated with an increased risk of inflammatory response syndrome and cardiac edema, resulting in delayed sternal closure, decreased respiratory compliance, acute lung injury, and coagulopathy or serious bleeding.…”

Section: Extubation In or After Congenital Heart Surgerymentioning

confidence: 99%

“…In 1980, Barash and colleagues 1) reported their experiences with early extubation, and more recently, several studies have suggested that extubation can be performed safely in the operating room (OR) for simple and complex surgical cases in all age groups. [2][3][4] However, the success rate of early extubation in children has been variable and dependent on inclusion and exclusion criteria, such as the patient's age, case severity, and procedure complexity. 5,6) An analysis using the Risk Adjustment in Congenital Heart Surgery method (RACHS-1) revealed that success rate of early extubation became more variable in complex, high-risk cases, such as those with pulmonary hypertension, excessive pulmonary blood flow with a degenerative vascular bed, and/or single ventricular physiology.…”

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confidence: 99%

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Early Extubation in the Operating Room after Congenital Open-Heart Surgery

et al. 2018

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SummaryEarly extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.(Int Heart J 2018; 59: 94-98)

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Section: Discussionmentioning

confidence: 99%

Section: Extubation In or After Congenital Heart Surgerymentioning

confidence: 99%

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confidence: 99%

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Early Extubation in the Operating Room after Congenital Open-Heart Surgery

et al. 2018

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“…Immunological mechanisms and anatomical characteristics are relatively different in children from those in adults (11,12). Prolonged mechanical ventilation following pediatric cardiac surgery was consistently associated with longer CPB time in other studies (13,14). Increased CPB time is required for more complex cases or if unexpected difficulties occur.…”

Section: Discussionmentioning

confidence: 93%

The Neutrophil Lymphocyte Ratio as a Successful Extubation Predictor of Prolonged Intubation in Pediatric Heart Surgery

et al. 2017

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Background: Postoperative mechanical ventilation is required in patients undergoing congenital heart surgery. However, the duration of mechanical ventilation may be extended as a result in some patients. Inflammation is a normal and expected process following surgery and the intensive care process. However, increased and prolonged inflammation increases the risk of mortality and morbidity. The neutrophil lymphocyte ratio (NLR) can be used as a new marker of inflammation in cardiovascular diseases. The aim of our study was to evaluate the association between NLR and successful extubation in pediatric patients undergoing cardiovascular surgery with prolonged intubation.

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“…[8][9][10][11] Some institutions have favored the use of epidural anesthesia. 8,12 This approach can allow for lower doses of opioids; however, it does carry some-albeit small-risk of infection and bleeding complications. Our CPG did not employ epidural anesthesia.…”

Section: Discussionmentioning

confidence: 99%

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery: Erratum

2018

Pediatric Critical Care Medicine

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Objective-To determine whether a collaborative learning strategy derived clinical practice guideline (CPG) can reduce the duration of endotracheal intubation following infant heart surgery.Design-Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre-and post-CPG implementation at the four sites participating in the collaborative (active sites) compared to data from five PHN centers not participating in collaborative learning (control sites).Patients-Data were collected for infants following 2 index operations: 1) repair of isolated coarctation of the aorta (birth-365 days) and 2) repair of tetralogy of Fallot (29-365 days). There were 240 subjects eligible for the CPG at active sites and 259 subjects at control sites.Measurements and Main Results-After CPG implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p<0.001) with no increase in reintubation rate. The median duration of post-operative intubation among active sites decreased from 21.2 hours to 4.5 hours (p<.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p=0.63). At active sites CPG implementation had no statistically significant impact on median intensive care unit (ICU) length of stay (LOS) (71.9 hours pre-vs. 69.2 post-implementation, p=0.29) for the entire cohort. There was a trend toward shorter ICU LOS in the tetralogy of Fallot subgroup (71.6 hours pre-vs. 54.2 postimplementation, p=0.068).Conclusions-A collaborative learning strategy designed CPG significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation CPG did not significantly change post-operative ICU LOS. Keywords mechanical ventilation; tetralogy of Fallot; outcomesCollaborative learning is a technique based upon principles from the manufacturing industry designed to bring low-performing processes into line with the highest-performing processes. Collaborative learning involves several key steps including: 1) topic selection; 2) learning sessions; and 3) action periods in which teams test and implement changes in their local centers. Through benchmarking, locations with superior outcomes are identified. In the medical community, this is achieved by site visits, sharing protocols, and ongoing communication.Investigators have applied collaborative learning to improve results for coronary artery bypass graft surgery by creating a regional group willing to compare outcomes. 1 This voluntary program, which involved reciprocal site visits, was undertaken with the goal of exchanging information concerning the treatment of cardiovascular disease so that each participating institution would benefit. A similar strategy has been used by other adult cardiovascular consortia to improve outcomes following valve surgery. 2,3 Collaborative learning using site visits has not yet been applied to pediatric cardiac care and thus it is unknown if it can improve outcomes in pediatric cardiac su...

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Extubation in the operating room after congenital heart surgery in children

Abstract: Extubation in the operating room after surgery for congenital heart disease was successful in the majority of patients. The strongest independent risk factors for failure of this strategy included younger age and longer cardiopulmonary bypass time.

Cited by 106 publications

References 23 publications

Early Extubation in the Operating Room after Congenital Open-Heart Surgery

Early Extubation in the Operating Room after Congenital Open-Heart Surgery

The Neutrophil Lymphocyte Ratio as a Successful Extubation Predictor of Prolonged Intubation in Pediatric Heart Surgery

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery: Erratum

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