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Factors affecting the decision to defer endotracheal extubation after surgery for congenital heart disease : a prospective observational study

Kin, Nobuhide; Weismann, Constance LU ; Srivastava, Shubhika; Chakravarti, Sujata; Bodian, Carol; Hossain, Sabera; Krol, Marina; Hollinger, Ingrid; Nguyen, Khanh and Mittnacht, Alexander J C (2011) In Anesthesia and Analgesia 113(2). p.35-329
Abstract

BACKGROUND: Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR).

METHODS: We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for... (More)

BACKGROUND: Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR).

METHODS: We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites.

RESULTS: Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria.

CONCLUSIONS: Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.

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author
publishing date
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Contribution to journal
publication status
published
keywords
Adolescent, Aging/physiology, Analgesics, Opioid, Anesthesia, Inhalation, Anesthetics, Dissociative, Anesthetics, Inhalation, Cardiopulmonary Bypass, Child, Child, Preschool, Down Syndrome/complications, Female, Heart Defects, Congenital/surgery, Humans, Infant, Infant, Newborn, Intubation, Intratracheal, Isoflurane, Ketamine, Male, Methyl Ethers, Morphine, Prospective Studies, Risk Adjustment, Risk Factors, Sevoflurane
in
Anesthesia and Analgesia
volume
113
issue
2
pages
35 - 329
publisher
Lippincott Williams & Wilkins
ISSN
1526-7598
DOI
10.1213/ANE.0b013e31821cd236
language
English
LU publication?
no
id
64487cfa-b8e1-4c4a-84cf-03a2fa75c9c2
date added to LUP
2019-01-25 14:46:46
date last changed
2019-07-27 04:00:51
@article{64487cfa-b8e1-4c4a-84cf-03a2fa75c9c2,
  abstract     = {<p>BACKGROUND: Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR).</p><p>METHODS: We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites.</p><p>RESULTS: Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria.</p><p>CONCLUSIONS: Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.</p>},
  author       = {Kin, Nobuhide and Weismann, Constance and Srivastava, Shubhika and Chakravarti, Sujata and Bodian, Carol and Hossain, Sabera and Krol, Marina and Hollinger, Ingrid and Nguyen, Khanh and Mittnacht, Alexander J C},
  issn         = {1526-7598},
  keyword      = {Adolescent,Aging/physiology,Analgesics, Opioid,Anesthesia, Inhalation,Anesthetics, Dissociative,Anesthetics, Inhalation,Cardiopulmonary Bypass,Child,Child, Preschool,Down Syndrome/complications,Female,Heart Defects, Congenital/surgery,Humans,Infant,Infant, Newborn,Intubation, Intratracheal,Isoflurane,Ketamine,Male,Methyl Ethers,Morphine,Prospective Studies,Risk Adjustment,Risk Factors,Sevoflurane},
  language     = {eng},
  number       = {2},
  pages        = {35--329},
  publisher    = {Lippincott Williams & Wilkins},
  series       = {Anesthesia and Analgesia},
  title        = {Factors affecting the decision to defer endotracheal extubation after surgery for congenital heart disease : a prospective observational study},
  url          = {http://dx.doi.org/10.1213/ANE.0b013e31821cd236},
  volume       = {113},
  year         = {2011},
}