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Extubation in the operating room after cardiac surgery in children: a prospective observational study with
Rajnish Garg1, Shekhar Rao1, Colin John1
1Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
Insights
Extubating children in the operating room after cardiac surgery is feasible, with an 87.1% success rate. This approach reduces intensive care unit (ICU) stays and hospital resource utilization without increasing mortality.
Area of Science:
- Pediatric Anesthesiology
- Cardiac Surgery
- Critical Care Medicine
Background:
- Pediatric cardiac surgery patients often require prolonged mechanical ventilation.
- Extubation in the operating room (OR) may optimize resource utilization and patient outcomes.
Purpose of the Study:
- To assess the feasibility and impact of extubating pediatric cardiac surgery patients in the OR.
Main Methods:
- Prospective observational study with historic controls (1000 patients each).
- Pediatric patients (1 day-18 years) undergoing cardiac surgery were candidates for OR extubation using general anesthesia and multimodal analgesia.
- Exclusion criteria included spinal deformity, neurologic issues, coagulopathy (INR > 1.5), and preoperative ventilation.
Main Results:
- 87.1% of patients were successfully extubated in the OR, with higher rates in older children.
- Re-intubation within 24 hours occurred in 4.5% of patients.
- The study group showed significantly shorter ICU length of stay (2.56 vs. 5.4 days) and reduced daily ICU and ventilator bed occupancy compared to historic controls (p<0.0001).
Conclusions:
- Operating room extubation is a safe and feasible strategy for pediatric cardiac surgery patients.
- This approach significantly decreases intensive care unit (ICU) length of stay and improves hospital resource utilization.
- No increase in mortality or morbidity was observed with OR extubation.
Objective:
This prospective observational study was undertaken to determine the feasibility of extubation of children in the operating room after cardiac surgery.
Design:
A prospective observational study compared with historic controls.
Setting:
A single tertiary care referral hospital.
Participants:
One thousand consecutive pediatric patients requiring cardiac surgery aged 1 day to 18 years. Patients with spinal deformity, neurologic problems, coagulopathy as diagnosed by high international normalized ratio (INR) more than 1.5, and patients preoperatively on mechanical ventilation were excluded from the study. Data were also reviewed for another 1,000 patients operated before the beginning of this study, which constituted historic controls.
Interventions:
All 1,000 patients were considered as potential candidates for extubation in the operating room after cardiac surgery and managed by a combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine, and extubation in the operating room was attempted after completion of the surgical procedure. These comprised the study group (SG). Data also were reviewed for another 1,000 patients before the beginning of this study when extubation in the operating room was not attempted and compared with this group to study the impact of extubation in the operating room on intensive care unit (ICU) stay and resource utilization. This data comprised the before-study group (BSG).
Measurements And Main Results:
Eight hundred seventy-one (87.1%) patients were extubated in the operating room. This included 40% of neonates and 70%, 85%, and 91% of patients aged between 1 and 3 months, 3 months to 1 year, and more than 1 year, respectively. Forty-five patients (4.5%) required re-intubation within 24 hours, and 9 patients died among those extubated in the OR, but for reasons thought not to be related to extubation. The ICU stay was significantly less in the study group (2.56±1.84 v 5.4±2.32 days, p<0.0001) as compared to before-study group (BSG). The number of patients in the ICU (34.76±3.19 v 59.98±4.92, p<0.0001) and the number of patients on a ventilator (5.1±1.24 v 24.5±2.88, p<0.0001) on a daily basis were significantly less in the study group, reflecting positive impact on resource utilization.
Conclusion:
Extubation in the operating room was successful in 87.1% of the patients without any increase in mortality and morbidity, but with a decrease in ICU length of stay and less use of hospital resources.
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