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Published on: August 2, 2024
Development of a Model Identifying Fontan Patients at High Risk for Failed Early Extubation in the Operating Room
Atsushi Kawaguchi1, Dominic Cave1, Qi Liu2
1Department of Pediatrics, Pediatric Critical Care Medicine, University of Alberta, Alberta, Canada.
Insights
A predictive model was developed to identify children at high risk for failed early extubation after the Fontan procedure. Key predictors include concomitant procedures, bypass time, and absence of fenestration, aiding clinical decision-making.
Area of Science:
- Pediatric Cardiac Surgery
- Critical Care Medicine
- Cardiovascular Research
Background:
- The Fontan procedure is a complex surgery for single-ventricle congenital heart defects.
- Early extubation in the operating room (OR) is a desirable strategy but carries risks.
- Identifying high-risk patients for failed early extubation is crucial for improving outcomes.
Purpose of the Study:
- To identify patients at high risk for failed early extubation in the OR following the Fontan procedure.
- To develop a predictive model for failed early extubation to aid clinical decision-making.
Main Methods:
- Retrospective review of 75 patients (0-17 years) undergoing the Fontan procedure (2008-2011).
- Comparison of patients requiring reintubation versus those not reintubated after OR extubation.
- Development of a two-stage logistic regression predictive model using pre/perioperative and postoperative predictors.
Main Results:
- The first-stage model identified concomitant procedure, total bypass time (≥99 minutes), and absence of fenestration as significant predictors.
- The second-stage model incorporated chest-tube fluid loss (CTFL ≥9.9 mL/kg/first 6 hours).
- The sequential prediction model achieved a net sensitivity of 87.5% and specificity of 77.6%.
Conclusions:
- A validated predictive model for failed early extubation in Fontan patients was developed.
- The model's sensitivity and specificity suggest clinical utility.
- Further validation with larger, independent samples is recommended.
Objective:
To identify patients at high risk for failed early extubation in the operating room (OR) following the Fontan procedure and generate a predictive model to allow improved clinical decision making.
Design:
The success of an early-extubation strategy (extubation in the OR) was reviewed in patients aged 0 to 17 years old, undergoing the Fontan procedure between 2008 and 2011. Patients who required reintubation following primary extubation in the OR were compared with those who did not. Logistic regression with a backward variable selection was used to develop a predictive model in two stages: first, using pre-/perioperative predictors and then using postoperative predictors among the first-stage positive.
Setting:
Canadian quaternary-care university children's hospital PICU. The treatment policy was changed from the routine extubation in PICU to extubation in the OR in January 2008.
Results:
A total of 75 patients met our inclusion criteria: 8 patients required reintubation. Patients' average body weight was 14.5 kg (standard deviation [SD] 3.7), average age was 3.5 (SD 1.9) years, and average preoperative transcutaneous arterial saturation was 80.9% (SD 6.8). The first-stage predictive model contained three predictors: concomitant procedure (odds ratio [OR] >999, 95% confidence interval [CI] 15.7-infinity, p < 0.001), total bypassing time (cutoff; ≥99 minutes) (OR >999, 95% CI 6.5-infinity, p < 0.001), and absence of fenestration for pre/operative variables (OR >999, 95% CI 9.5-infinity, p < 0.001). The second-stage model included chest-tube fluid loss (CTFL ≥9.9 mL/kg/first 6 h). Our sequential prediction model had net sensitivity of 87.5% and specificity of 77.6%.
Conclusion:
We produced a predictive model for failed early extubation in Fontan patients. The sensitivity and specificity values are in the range of clinical utility. The model should be validated with an independent sample with a larger sample size.
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