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Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness
Daniel L Hames1,2, Lynn A Sleeper2,3, Kevin J Bullock4
1Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, MA.
Insights
Extubation failure in pediatric cardiac surgery patients is linked to younger age, male sex, complex procedures, and preoperative respiratory support. Current readiness tests lack sensitivity, and new indices require further study.
Area of Science:
- Pediatric Cardiac Surgery
- Critical Care Medicine
- Respiratory Physiology
Background:
- Extubation failure post-cardiac surgery in children is a significant concern, linked to increased morbidity and mortality.
- Existing extubation readiness tests (ERT) may not adequately assess non-respiratory support needs in pediatric congenital heart disease patients on mechanical ventilation (MV).
Purpose of the Study:
- To identify factors associated with extubation failure in children after cardiac surgery.
- To evaluate the performance of risk analytics algorithms, including the inadequate delivery of oxygen (IDO2) index, in predicting extubation failure.
Main Methods:
- Retrospective cohort study of children receiving MV >48 hours post-cardiac surgery.
- Analysis of 650 encounters to identify predictors of reintubation.
- Assessment of institutional ERT performance and the impact of adding the IDO2 index.
Main Results:
- Extubation failure (reintubation) occurred in 8% of cases, most frequently within 6 hours.
- Younger age, male sex, STS-ECATS category 5 procedures, and preoperative respiratory support were independent predictors of reintubation.
- The institutional ERT showed low sensitivity (23.8%); adding the IDO2 index improved sensitivity but reduced overall accuracy.
Conclusions:
- Preoperative respiratory support, younger age, and complex operations are associated with extubation failure.
- The inadequate delivery of oxygen (IDO2) index offers unique monitoring parameters but needs further investigation for clinical use in extubation readiness assessments.
Objectives:
Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT.
Design:
Retrospective cohort study.
Setting:
CICU at a tertiary-care children's hospital.
Patients:
Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019.
Interventions:
None.
Measurements And Main Results:
Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01).
Conclusions:
Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.
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