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

Abstract

Objective In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. Methods We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. Results The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18%had major extracardiac anomalies, and 74%underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95%confidence interval, 1.4–6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). Conclusions This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.

Multicenter Validation of the Vasoactive-Ventilation-Renal Score as a Predictor of Prolonged Mechanical Ventilation After Neonatal Cardiac Surgery*

“…Interestingly, we found that 32% of patients within our cohort were classified by this ICD-10 code as having prolonged duration of mechanical ventilation, which is close to the upper 25% chosen in prior studies of the VVR (8-10). Our definition for prolonged duration of mechanical ventilation is further justified by data from a recent a large multicenter cohort of neonates recovering from cardiac surgery, which reported a median duration of mechanical ventilation of 70 hours (17). We were also aware that all but two of the patients were endotracheally intubated on mechanical ventilation upon arrival to the ICU.…”

Epidemiology of Noninvasive Ventilation in Pediatric Cardiac ICUs*

“…A previously published study aimed to identify predictors of success of NIV in preventing extubation failure, though the retrospective nature of the study makes it challenging to draw conclusions in how NIV can best be used to prevent extubation failure [7]. The impact of different NIV strategies on reintubation rates remains a major outstanding question, and future trials are warranted based on our understanding of variation in extubation failure across hospitals [15, 16]. …”

Near-infrared spectroscopy for prediction of extubation success after neonatal cardiac surgery

“…2,3 Neonates in particular have a higher rate of extubation failure (12 %) as compared to older children. [3][4][5] Reported rates of extubation failure after neonatal cardiac surgery range from 5 to 23 %. 3,5,6 Common indicators utilised for assessing extubation readiness following congenital heart surgery include subjective and objective measures of neuromuscular function and oxygenation and ventilation and indirect markers of adequate cardiac output.…”

“…[3][4][5] Reported rates of extubation failure after neonatal cardiac surgery range from 5 to 23 %. 3,5,6 Common indicators utilised for assessing extubation readiness following congenital heart surgery include subjective and objective measures of neuromuscular function and oxygenation and ventilation and indirect markers of adequate cardiac output. 4 However, extubation readiness tools that have incorporated these indicators have not yet been proven to be reliable in neonates.…”