Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery*

Abstract

Objective: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, though data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. Design: Retrospective chart reviewSetting: Urban tertiary care free-standing children's hospital Interventions: Extubation failure was defined as re-intubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. Measurements & Main Conclusions:Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.3

Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals

“…4,5 Neonates in the cardiac ICU consistently have demonstrated an increased risk of extubation failure relative to their pediatric counterparts; previous investigation focusing on these patients consistently report extubation failure rates from 17.5% to 22.0% of patients compared with overall rates of approximately 6% in all patients in the cardiac ICU. 4,7,8 These studies also suggest worse clinical outcomes associated with extubation failure in neonates. 7–9 …”

Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis

“…[7] Patients who underwent endotracheal intubation and another period of mechanical ventilation that was initiated after 72 hours from the first extubation attempt were considered successful initial extubations. A comprehensive list of variables collected and additional definitions are included in Table 1 (online).…”

“…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.…”

“…In many cases, despite reassuring respiratory and hemodynamic indices, extubation failure still occurs. Initial studies focused on extubation failure after surgery for congenital heart disease in neonates, while providing some valuable insight, have been restricted to small single center cohorts and thus have had limited generalizability [6,7,9] In a recent review of data from the Pediatric Cardiac Critical Care Consortium (PC4), only the presence of an underlying anatomic airway anomaly could be identified as an independent risk factor for extubation failure after neonatal cardiac surgery, but the analysis in this study was limited to the variables available within the registry [10]. We aimed to describe the epidemiology of extubation failure in a large multicenter population of neonates undergoing surgery for congenital heart disease.…”

“…Our data also suggest that the length of time mechanically-ventilated does not independently effect the likelihood of extubation success or failure in neonatal cardiac surgical patients. Likewise, in the only prior single center study to examine extubation failure in a heterogeneous group of neonates who underwent cardiac surgery and in the study recently presented from the PC4 database, no independent effect of duration of mechanical ventilation on the likelihood of extubation failure was found [7,10] In contrast, recent data from a large cohort of children of all age groups with critical cardiac disease (the majority of which underwent cardiac surgery), demonstrated duration of mechanical ventilation to be the most important risk factor for extubation failure [5]. Hence, while most clinicians commonly have heightened awareness of the risk of extubation failure in patients who have required prolonged mechanical ventilation, this increased concern for extubation failure should be applied to all neonates following cardiac surgery, whether extubation is occurring early or late in their course.…”