High Mortality Rate After Extubation Failure After Pediatric Cardiac Surgery

Abstract

The objective of this study was to evaluate the different causes of extubation failure and the consequent mortality rates in a pediatric population after cardiac surgery. We studied 184 consecutive patients with a median age of 9 months (range, 0-165). In 158 patients, extubation was successful (group A). Nine patients were reintubated for upper airway obstruction and finally extubated successfully (group B). Seventeen patients were reintubated for cardiorespiratory failure, finally leading to death in 11 of 17 patients (65%) (group C). Group B patients were younger and had a longer intubation period compared to group A patients. Group C patients had more reoperations (30% vs 4% in group A patients, p < 0.001), a lower PaO2 on admission at the intensive care unit as well as just prior to extubation, a lower base deficit before extubation, and needed more inotropic support during their stay in the intensive care unit. We conclude that extubation failure after pediatric cardiac surgery due to cardiorespiratory failure is a bad prognostic sign. Patients with high inotropic support and a low PaO2 prior to extubation are especially at risk and probably need careful evaluation before final extubation.

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

“…In our study, extubation failure occurred in nearly one-fifth of neonates, which is consistent with the range of 10-27% reported in other studies of children recovering from pediatric cardiac surgery [10][11][12][13][14][15]. The definition of extubation failure has varied in prior studies examining extubation failure in children with cardiac disease [10][11][12][13][14][15], with some defining extubation failure as the need for re-intubation within 24-48 hours while others have used 96 hours as their definition. Authors who have employed the latter definition [13][14][15] have asserted that extubation failure in patients with underlying cardiac disease can be slow to evolve and thus the time frame for extubation failure should be expanded beyond 48 hours.…”

“…Extubation failure is often tumultuous in these patients, and can be associated with considerable postoperative morbidity and prolonged length of stay in the intensive care unit, especially in neonates [10]. To date, existing literature that has reported risk factors for extubation failure specific to patients recovering from pediatric cardiac surgery have been either large heterogeneous groups of children that ranged widely in age [11][12] or smaller studies focused on specific lesions [13][14][15]. We hypothesized that a study focused solely on neonates but inclusive of all neonatal cardiac lesions would not only identify patient characteristics associated with extubation failure but would also identify specific cardiac defects at increased risk for this undesirable outcome.…”

Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery

“…For example, upper airway obstruction leading to extubation failure has been implicated in 2-4% of patients in studies focused on children recovering from cardiac surgery. [6][7][8] Interestingly, one of these studies, 4 of 7 patients who failed extubation did so in the operating room secondary to extrathoracic upper airway obstruction, 8 indicating, as also demonstrated in our report, that patients need not be endotracheally intubated for prolonged periods of time to experience post-extubation stridor. In two studies of patients requiring tracheostomy following cardiac surgery, extrathoracic upper airway obstruction followed by tracheostomy placement occurred in 0.2% and 0.5% of patients.…”

“…Upper airway obstruction has also been implicated as important contributor to extubation failure, which has been associated with increased morbidity and mortality in this patient population. [6][7][8] In the most severe cases, tracheostomy is required to facilitate long-term recovery. [9][10][11] Current literature cites wide-ranging incidences of upper airway obstruction in the non-cardiac pediatric ICU population from 5-40%.…”

Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis

“…Following reintubation, these neonates are then committed to another course of mechanical ventilation, with its inherent risks and exposures such as ventilator-associated infections, airway trauma, and the need for sedative infusions. In neonates and children undergoing cardiac surgery, extubation failure has been consistently associated with increased postoperative morbidity and mortality [3][4][5][6][7]. Prevention of this important complication is therefore an essential part of optimizing clinical outcomes in this patient population.…”