Three-year experience with immediate extubation in pediatric patients after congenital cardiac surgery

Abstract

BackgroundIn pediatric cardiac anesthesiology, there is increased focus on minimizing morbidity, ensuring optimal functional status, and using health care resources sparingly. One aspect of care that has potential to affect all of the above is postoperative mechanical ventilation. Historically, postoperative ventilation was considered a must for maintaining patient stability. Ironically, it is recognized that mechanical ventilation may increase risk of adverse outcomes in the postoperative period. Hence, many institutions have advocated for immediate extubation or early extubation after many congenital heart surgeries which was first reported decades ago.Methods637 consecutive patient charts were reviewed for pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Patients were placed into three groups. Those that were extubated in the operating room (OR) at the conclusion of surgery (Immediate Extubation or IE), those that were extubated within six hours of admission to the ICU (Early Extubation or EE) and those that were extubated sometime after six hours (Delayed Extubation or DE). Multiple variables were then recorded to see which factors correlated with successful Immediate or Early Extubation.ResultsOverall, 338 patients (53.1%) had IE), 273 (42.8%) had DE while only 26 patients (4.1%) had EE. The median age was 1174 days for the IE patients, 39 days for the DE patients, whereas 194 days for EE patients (p < 0.001). Weight and length were also significantly different in at least one extubation group from the other two (p < 0.001). The median ICU LOS was 3 and 4 days for IE and EE patients respectively, whereas it was 9.5 days for DE patients (p < 0.001). DE group had a significant longer median anesthesia time and cardiopulmonary bypass time than the other two extubation groups (p > 63,826.88 < 0.001). Regional low flow perfusion, deep hypothermia, deep hypothermic circulatory arrest, redo sternotomy, use of other sedatives, furosemide, epinephrine, vasopressin, open chest, cardiopulmonary support, pulmonary edema, syndrome, as well as difficult intubation were significantly associated with delayed extubation (IE, EE or DE).ConclusionsImmediate and early extubation was significantly associated with several factors, including patient age and size, duration of CPB, use of certain anesthetic drugs, and the amount of blood loss and blood replacement. IE can be successfully accomplished in a majority of pediatric patients undergoing surgery for congenital heart disease, including in a minority of infants.

A mechanism for improved talc pleurodesis via foam delivery

“…The similarity in results suggests that both methods lead to poor talc dispersion on the pleural tissue. In previous work (Laub et al., 2017 ; Baxter et al., 2020 ) we showed that foam drug-delivery systems improve talc pleurodesis. The foams formulations without talc were not able to induce pleural adhesions (Baxter et al., 2020 ).…”

“…In previous work (Laub et al., 2017 ; Baxter et al., 2020 ) we showed that foam drug-delivery systems improve talc pleurodesis. The foams formulations without talc were not able to induce pleural adhesions (Baxter et al., 2020 ). It has been hypothesized that the increased efficacy of foam pleurodesis over talc slurry is due to the high volume of foam injected into the pleural cavity, which increases the dispersion of talc on the tissue surface (Laub et al., 2017 ).…”

Embolization of an Atrial Septal Defect Occluder Device Into the Left Ventricle

“…The occlusion techniques using this device include classic percutaneous ASD occlusion under fluoroscopy, percutaneous procedure under ultrasound-guidance, and intra-operative device close under ultrasound-guidance [ 1 ]. While percutaneous occlusion is generally considered effective and safe for patients with secundum ASD, limitations with this technique using fluoroscopy include damaging radiation exposure and higher risk for complications for children under 10 years of age [ 1 , 2 ]. The size and rim of the ASD in addition to the size of the occluder are also important to consider when using the percutaneous approach.…”

Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance during General Anesthesia—A New Era in Patient Safety Standards and Healthcare Management

“…Numerous studies have shown that opioid overdose during anesthesia is responsible for a series of adverse effects, such as increased recovery times and opioid induced hyperalgesia, and that opioid overdose also leads to hypotension, having a major impact on perioperative hemodynamic stability [ 66 , 67 , 68 , 69 , 70 , 71 ]. Won et al reported that using SPI monitoring during general anesthesia reduced opioid consumption, improved hemodynamic stability, and reduced postoperative recovery times [ 71 ].…”

“… Technologies/parameters used for monitoring the nociception-antinociception balance [ 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. ANI—analgesia nociception index; qNOX index—index of nociception; SPI—Surgical Plethysmographic Index; NOL index—Nociception Level Index; EEG—Electroencephalography; EMG—Electromyography signal.…”