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Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant
Venu Amula1, David F Vener2, Charles G Pribble1
1Department of Pediatrics, University of Utah, Salt Lake City, UT.
Insights
Implementing an early extubation guideline for infants undergoing heart surgery reduced opioid and benzodiazepine use. Intraoperative dexmedetomidine (a sedative) was linked to faster extubation, improving patient recovery.
Area of Science:
- Pediatric Anesthesiology
- Critical Care Medicine
- Cardiovascular Surgery
Background:
- Infants undergoing repair of coarctation of the aorta or tetralogy of Fallot often require mechanical ventilation.
- Early extubation in these high-risk pediatric patients can be challenging but beneficial.
Purpose of the Study:
- To compare anesthetic and sedation-analgesia management before and after implementing a clinical practice guideline for early extubation.
- To identify factors associated with early extubation in infants after cardiac repair.
Main Methods:
- Secondary analysis of data from a multicenter study (2013-2015) involving 240 pediatric patients.
- Comparison of anesthetic, sedative, and analgesic exposure pre- and post-guideline implementation.
- Propensity score weighted logistic regression to assess the effect of dexmedetomidine on early extubation.
Main Results:
- Guideline implementation decreased intraoperative opioid and benzodiazepine doses but did not alter volatile anesthetic exposure.
- Intraoperative dexmedetomidine administration was independently associated with early extubation (OR 2.5, P=0.04).
- Post-guideline, more patients received dexmedetomidine in the ICU, with decreased benzodiazepine use.
Conclusions:
- An early extubation guideline effectively reduced opioid and benzodiazepine requirements without changing volatile anesthetic use.
- Intraoperative dexmedetomidine is a key factor associated with successful early extubation in this population.
- The guideline improved postoperative sedation-analgesia management, reducing benzodiazepine exposure.
Objectives:
The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation.
Design:
Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation.
Setting:
Five children's hospitals.
Patients:
A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation).
Interventions:
None.
Measurements And Main Results:
Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation.
Conclusions:
The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
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