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Extubation failure in infants with shunt-dependent pulmonary blood flow and univentricular physiology

Published online by Cambridge University Press:  18 January 2013

Punkaj Gupta ,
Rachel McDonald ,
Sunali Goyal ,
Jeffrey M. Gossett ,
Michiaki Imamura ,
Amit Agarwal ,
Warwick Butt  and
Adnan T. Bhutta
Punkaj Gupta*
Affiliation:
Division of Pediatric Cardiology, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Rachel McDonald
Affiliation:
Division of Pediatric Cardiology, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Sunali Goyal
Affiliation:
Department of Ophthalmology, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Jeffrey M. Gossett
Affiliation:
Department of Biostatistics, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Michiaki Imamura
Affiliation:
Department of Pediatric Cardiothoracic Surgery, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Amit Agarwal
Affiliation:
Division of Pediatric Pulmonology, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
Warwick Butt
Affiliation:
Department of Pediatric Intensive Care, The Royal Children's Hospital, Melbourne, Australia
Adnan T. Bhutta
Affiliation:
Division of Pediatric Cardiology, University of Arkansas Medical Center, Little Rock, Arkansas, United States of America
*
Correspondence to: Dr P. Gupta, MBBS, College of Medicine, University of Arkansas for Medical Sciences, Sections of Pediatric Cardiology and Critical Care Medicine, Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, Arkansas, United States of America. Tel: 501 364 1479; Fax: 501 364 3667; E-mail: [email protected]
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Abstract

Objective

The objective of the study was to identify incidence, aetiology, and outcomes of extubation failure in infants with shunt-dependent pulmonary blood flow at a single tertiary care, academic children's hospital. The second objective of this study was to determine the haemodynamic effects of transition of positive pressure ventilation to spontaneous breathing in infants with extubation failure.

Patients and methods

Extubation failure for our study was defined as the need for positive pressure ventilation within 96 hours after extubation. We collected demographics, pre-operative, intra-operative, post-operative, and peri-extubation data in a retrospective, observational format in patients who underwent a modified Blalock–Taussig shunt between January, 2005 and March, 2011. Infants undergoing Norwood operation or Damus–Kaye–Stansel with modified Blalock–Taussig shunt were excluded from the study. The cardiorespiratory variables collected before extubation and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near infrared spectroscopy, oxygen saturations, and lactate levels. Clinical outcomes evaluated included the success or failure of extubation, cardiovascular intensive care unit length of stay, hospital length of stay, and mortality. Descriptive and univariate statistics were utilised to compare groups with extubation failure and extubation success.

Results

Of the 55 eligible patients during the study period, extubation failure occurred in 27% (15/55) of the patients. Of the 15 patients with extubation failure, 10 patients needed reintubation and five patients received continuous positive pressure ventilation without getting reintubated. There were three patients who had extubation failure in the first 2 hours after extubation, nine patients in the 2–24-hour period, and three patients in the 24–96-hour period. In all, eight patients were extubated in the second attempt after the first extubation failure, with a median duration of mechanical ventilation of 2 days (1 day, 6 days). The median age of patients at extubation was 19 days (12 days, 22 days) and median weight of patients was 3.6 kg (3.02 kg, 4.26 kg). In all, 38% (21/55) of the patients were intubated before surgery. The most common risk factors for failed extubation were lung disease in 46% (7/15), cardiac dysfunction in 26% (4/15), diaphragmatic paralysis in 13% (2/15), airway oedema in 6% (1/15), and vocal cord paralysis in 6% (1/15). The median duration of mechanical ventilation was 4 days (1 day, 10.5 days), median cardiovascular intensive care unit length of stay was 11 days (6.5 days, 23.5 days), and the median hospital length of stay was 30 days (14 days, 48 days). The overall mortality at the time of hospital discharge was 7%.

Conclusions

Extubation failure in infants with shunt-dependent pulmonary blood flow and univentricular physiology is high and aetiology is diverse. Cardiopulmonary effects of removal of positive pressure ventilation are more pronounced in children with extubation failure and include escalation in the need for oxygen requirement and increase in mean arterial blood pressure. The majority of extubation failures in this select patient population occurs in the first 24 hours. Extubation failure in these patients is not associated with increased hospital length of stay or mortality.

Keywords

Extubation failurereintubationmechanical ventilationcardiac surgerycardiac intensive care unitcongenital heart disease
Type
Original Articles
Information
Cardiology in the Young , Volume 24 , Issue 1 , February 2014 , pp. 64 - 72
Copyright
Copyright © Cambridge University Press 2013 

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References

1. Cox, AC, Piedmonte, M, Drummond-Webb, JJ, et al. Factors associated with prolonged mechanical ventilation in children following cardiothoracic surgery. Crit Care Med 2000; 28: A75.Google Scholar
2. Kanter, RK, Bove, EL, Tobin, JR, et al. Prolonged mechanical ventilation of infants after open heart surgery. Crit Care Med 1986; 14: 211–214.CrossRefGoogle ScholarPubMed
3. Harrison, AM, Cox, AC, Davis, S, Piedmonte, M, Drummond-Webb, JJ, Mee, RB. Failed extubation after cardiac surgery in young children: prevalence, pathogenesis, and risk factors. Pediatr Crit Care Med 2002; 3: 148–152.CrossRefGoogle ScholarPubMed
4. Khan, N, Brown, A, Venkataraman, ST. Predictors of extubation success and failure in mechanically ventilated infants and children. Crit Care Med 1996; 24: 1568–1579.CrossRefGoogle ScholarPubMed
5. Tobin, MJ, Perez, W, Guenther, SM, et al. The pattern of breathing during successful and unsuccessful trials of weaning from mechanical ventilation. Am Rev Respir Dis 1986; 134: 1111–1118.Google ScholarPubMed
6. Freely, TW, Hedley-Whyte, J. Weaning from controlled ventilation and supplemental oxygen. N Engl J Med 1975; 292: 903–906.Google Scholar
7. Balsan, MJ, Jones, JG, Watchko, JF, et al. Measurements of pulmonary mechanics prior to elective extubation of neonates. Pediatr Pulmonol 1990; 9: 238–243.CrossRefGoogle ScholarPubMed
8. Johnston, C, de Carvalho, WB, Piva, J, Garcia, PC, Fonseca, MC. Risk factors for extubation failure in infants with severe acute bronchiolitis. Respir Care 2010; 55: 328–333.Google ScholarPubMed
9. Laussen, PC, Roth, SJ. Fast tracking: efficiently and safely moving patients through the intensive care unit. Prog Pediatr Cardiol 2003; 18: 149–158.CrossRefGoogle Scholar
10. Kloth, R, Baum, V. Very early extubation in children after cardiac surgery? Crit Care Med 2002; 30: 787–791.CrossRefGoogle ScholarPubMed
11. Vricells, LA, Dearani, JA, Grundy, SR, et al. Ultra-fast track in elective congenital heart surgery. Ann Thorac Surg 2000; 69: 865–871.CrossRefGoogle Scholar
12. Bandla, HP, Hopkins, RL, Beckerman, RC, Gozal, D. Pulmonary risk factors compromising postoperative recovery after surgical repair for congenital heart disease. Chest 1999; 116: 740–747.CrossRefGoogle ScholarPubMed
13. Schuller, JL, Bovill, JG, Nijveld, A, Patrick, MR, Marcelletti, C. Early extubation of the trachea after open heart surgery for congenital heart disease. A review of 3 years’ experience. Br J Anaesth 1984; 56: 1101–1108.CrossRefGoogle ScholarPubMed
14. Ko, WJ, Lin, CY, Chen, RJ, Wang, SS, Lin, FY, Chen, YS. Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock. Ann Thorac Surg 2002; 73: 538–545.CrossRefGoogle ScholarPubMed
15. Goldstein, B, Giroir, B, Randolph, A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6: 2–8.CrossRefGoogle ScholarPubMed
16. Gupta, P, McDonald, R, Gossett, JM, et al. A single center experience of extubation failure in infants undergoing the Norwood operation. Ann Thorac Surg, 2012 July 10. [Epub ahead of print].CrossRefGoogle Scholar
17. Bronicki, RA, Herrera, M, Mink, R, et al. Hemodynamics and cerebral oxygenation following repair of tetralogy of Fallot: the effects of converting from positive pressure ventilation to spontaneous breathing. Congenit Heart Dis 2010; 5: 416–421.CrossRefGoogle ScholarPubMed
18. Jenkins, J, Lynn, A, Edmonds, J, Barker, G. Effects of mechanical ventilation on cardiopulmonary function in children after open-heart surgery. Crit Care Med 1985; 13: 77–80.CrossRefGoogle ScholarPubMed
19. Székely, A, Sápi, E, Király, L, Szatmári, A, Dinya, E. Intraoperative and postoperative risk factors for prolonged mechanical ventilation after pediatric cardiac surgery. Paediatr Anaesth 2006; 16: 1166–1175.CrossRefGoogle ScholarPubMed