Early Extubation Following Pediatric Cardiothoracic Operation: A Viable Alternative

doi:10.1016/S0003-4975(10)61872-3

The Annals of Thoracic Surgery

Volume 29, Issue 3, March 1980, Pages 228-233

https://doi.org/10.1016/S0003-4975(10)61872-3 Get rights and content

Abstract

A protocol is presented that facilitates early extubation following pediatric cardiothoracic operations. A total of 197 consecutive patients were managed according to this protocol. Fifty percent of the patients were less than 3 years old. Cardiopulmonary bypass was required in 113 (57%) of the surgical procedures. Extubation immediately following the surgical procedure was accomplished in 142 (72%) of the patients. Pulmonary complications occurred in 8 of these 142 patients (6%) and in 10 (18%) of the 55 patients requiring postoperative mechanical ventilation. Of the patients having early extubation, 5 (4%) required reintubation. One death in this group was unrelated to pulmonary function. There were 16 deaths among the 55 patients managed with mechanical ventilation. Carefully conducted early extubation provided specific advantages over routine postoperative mechanical ventilation. Modern techniques of anesthesia and surgical repair of congenital heart disease can decrease the requirement for postoperative mechanical ventilation and the potential for related complications.

References (14)

DM Aviado
Regulation of bronchomotor tone during anesthesia
Anesthesiology
(1975)
PG Barash et al.
Markedly improved pulmonary function after open heart surgery in infancy utilizing surface cooling, profound hypothermia, and circulatory arrest
Am J Surg
(1976)
EF Battersby et al.
Management of respiratory insufficiency in infants with congenital heart disease
Int Anesthesiol Clin
(1974)
JJ Downes et al.
Acute respiratory failure in infants following cardiovascular surgery
J Thorac Cardiovasc Surg
(1970)
CA Hirshman et al.
Halothane and enflurane protect against bronchospasm in an asthma dog model
Anesth Analg (Cleve)
(1978)
I Ingersoll et al.
The role of profound hypothermia in infants undergoing surgical correction of complicated heart defects
Anesth Analg (Cleve)
(1975)
WS Jordan et al.
New therapy for post-intubation laryngeal edema and tracheitis in children
JAMA
(1970)

There are more references available in the full text version of this article.

Cited by (91)

On-table Extubation After Minimally Invasive Cardiac Surgery: A Retrospective Observational Pilot Study
2023, Journal of Cardiothoracic and Vascular Anesthesia
To assess the safety of “on-table” extubation after minimally-invasive heart valve surgery.
A single-center retrospective observational study.
At a tertiary referral academic hospital.
Patients who underwent nonemergent isolated heart valve surgery through a minithoracotomy approach between January 2016 and August 2021.
All patients were treated by 1 of the 6 cardiac anesthesiologists of the hospital. Only some of them practiced “on-table” extubation, and the outcome of patients extubated “on-table” was compared to those extubated in the intensive care unit (ICU).
The primary outcome was the occurrence of any postoperative respiratory complication during the entire hospital stay. Secondary outcomes included the use of inotropes and vasopressors, de novo atrial fibrillation, and lengths of stay in the ICU and the hospital. A total of 294 patients met inclusion criteria, of whom 186 (63%) were extubated “on-table.” Cardiopulmonary bypass duration was significantly longer, and moderate intraoperative hypothermia was significantly more frequent in patients extubated in the ICU. After adjustment for these confounders and for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II using a multivariate logistic model, no association was found between the extubation strategy and postoperative pulmonary complications (adjusted odds ratio = 0.84; 95% CI = 0.40-1.77; p = 0.64). “On-table” extubation was associated with a lower risk of postoperative pneumonia and fewer vasopressors requirements.
“On-table” extubation was not associated with an increased incidence of respiratory complications. A randomized controlled trial is warranted to confirm these results and determine whether “on-table” extubation offers additional benefits.
Commentary: It's all about what the patient needs, not what we are used to or comfortable with
2021, Journal of Thoracic and Cardiovascular Surgery
Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?
2021, Journal of Thoracic and Cardiovascular Surgery
To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery.
Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared.
Of 717 infants (median age: 4 months, Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group.
FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.
In Celebration of the Life and Contributions of Paul G. Barash
2021, Journal of Cardiothoracic and Vascular Anesthesia
Dr. Paul G Barash, former Chair of the Department Of Anesthesiology at the Yale University School of Medicine, died on June 8, 2020 at the age of 78. He was one of the giants in anesthesiology: a notable clinician, investigator, teacher, and founding editor of his internationally renowned textbook Clinical Anesthesia. However, he was in particular a pioneer and leader in the subspecialty of cardiac anesthesia. In this review, we summarize his career, the contributions he made to the practice of anesthesiology in general and to cardiac anesthesia in particular and provide comments from his colleagues and friends. We summarize the attributes of this man that made him a model of our profession that we can all strive to emulate.
Implementation of On-table Extubation After Pediatric Cardiac Surgery in the Developing World
2020, Journal of Cardiothoracic and Vascular Anesthesia
Predictors of early extubation after pediatric cardiac surgery: Fifteen months of institutional experience
2020, Progress in Pediatric Cardiology
Citation Excerpt :
In addition, successful extubation is generally accompanied by a reduction in the use of sedatives such as benzodiazepines (among others), which are currently being studied because of their potential negative impact on neurodevelopmental outcomes [1]. Although an initial experience with early extubation (EE) after CHS is not a new concept and was first published in 1980 by Barash and colleagues [2], most PICUs continue to allow rewarming, arousal from anesthesia, and the establishment of a stable hemodynamic status with minimal chest tube bleeding and adequate oxygenation and ventilation (with evidence of acceptable lung compliance) before weaning from MV. Furthermore, CPB can trigger a systemic inflammatory response resulting in end-organ dysfunction, and a subset of these patients develop multiorgan system failure that can manifest as capillary leak syndrome, coagulopathy, respiratory and myocardial dysfunction, renal insufficiency, and neurocognitive decline [3–4].
The many advantages of early extubation following cardiac surgery in children are now widely recognized. We sought to identify factors associated with successful and early extubation in children undergoing congenital heart surgery, including neonates (aged <30 days).
From June 2017 to September 2018 a total of 145 patients, including 17 neonates (12%) and 76 (52%) children aged under 1 year underwent 155 surgeries. Early and delayed extubation were defined respectively as removal of the endotracheal tube within 6 h or >6 h from arrival to PICU following cardiac surgery. Demographic, preoperative, intraoperative, and postoperative data were analysed retrospectively.
Early extubation (<6 h) was achieved in 59% of the cases. In 10 cases an initial extubation attempt failed at a median of 17 h with a global failed extubation rate of 6.5%. Multivariate logistic regression analyses were used to determine independent relationships between perioperative factors and early extubation and demonstrated that predictors of early extubation included a lower Risk Adjustment in Congenital Heart Surgery (RACHS-1) scores and the absence of preoperative mechanical ventilation.
We established that successful early extubation can be accomplished within the first 6 post-surgery hours in low-to-medium risk pediatric cardiac surgery patients.

View all citing articles on Scopus

: We thank the nursing staff of the Dana Recovery Room for their invaluable assistance.

View full text

Early Extubation Following Pediatric Cardiothoracic Operation: A Viable Alternative

Abstract

Regulation of bronchomotor tone during anesthesia

Anesthesiology

Markedly improved pulmonary function after open heart surgery in infancy utilizing surface cooling, profound hypothermia, and circulatory arrest

Am J Surg

Management of respiratory insufficiency in infants with congenital heart disease

Int Anesthesiol Clin

Acute respiratory failure in infants following cardiovascular surgery

J Thorac Cardiovasc Surg

Halothane and enflurane protect against bronchospasm in an asthma dog model

Anesth Analg (Cleve)

The role of profound hypothermia in infants undergoing surgical correction of complicated heart defects

Anesth Analg (Cleve)

New therapy for post-intubation laryngeal edema and tracheitis in children

JAMA