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Trends in Time to Extubation for Pediatric Postoperative Cardiac Patients and Its Correlation With Changes in
Rebecca Epstein1, Shelley J Ohliger2, Ira M Cheifetz3
1Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY.
Insights
Early extubation after pediatric cardiac surgery did not change survival or ICU length of stay but lowered reintubation rates. This practice is safe and effective for improving patient outcomes.
Area of Science:
- Pediatric Cardiac Surgery
- Mechanical Ventilation
- Critical Care Medicine
Background:
- Mechanical ventilation is standard post-pediatric cardiac surgery but carries risks like hemodynamic compromise and lung injury.
- Early extubation is hypothesized to improve outcomes, including reduced intensive care unit (ICU) length of stay and enhanced survival.
Purpose of the Study:
- To analyze trends in early extubation rates for children undergoing cardiac surgery from 2009 to 2018.
- To evaluate the association between center-level early extubation practices and severity-adjusted patient outcomes, including ICU length of stay, mortality, and extubation failure.
Main Methods:
- Retrospective analysis of the Virtual Pediatric Systems (VPS) database (2009-2018).
- Inclusion of pediatric patients undergoing cardiac surgery.
- Definition of early extubation as extubation in the operating room or within 6 hours of pediatric intensive care unit (PICU) admission.
Main Results:
- Out of 69,739 subjects, 47% underwent early extubation; rates remained stable over the study period.
- Centers with higher early extubation rates showed no significant improvement in ICU-free days or mortality after multivariable adjustment.
- Higher center-level early extubation rates were associated with a significantly decreased rate of extubation failure (3.6% vs. 6.4%).
Conclusions:
- Early extubation rates in pediatric cardiac surgery patients did not change significantly between 2009 and 2018.
- While not associated with shorter ICU stays or improved survival, increased early extubation frequency at the center level correlated with lower rates of reintubation.
- These findings suggest that early extubation is a safe strategy that may reduce the need for reintubation in this patient population.
Objectives:
Mechanical ventilation is often used in children after cardiac surgery but can impair hemodynamics and cause lung injury. Early extubation may improve ICU length of stay and survival. We aimed to describe trends in early extubation rates and evaluate if centers that more commonly practice early extubation have better severity-adjusted outcomes.
Design:
Retrospective analysis was performed of admissions in the Virtual Pediatric Systems (VPS, LLC) database from 2009 to 2018. Early extubation was defined as patients extubated in the operating room or within 6 hours of PICU admission.
Setting:
PICUs participating in the VPS database.
Patients:
Children in the VPS database who underwent cardiac surgery.
Interventions:
None.
Measurement And Main Results:
Among 69,739 subjects, 20% were neonates, 47% underwent early extubation, 5.3% failed extubation, and 2.5% died. Overall, early extubation rates did not change over the study period. Centers were placed in one of four groups based on their early extubation rate in lower complexity surgeries. Centers that most commonly used early extubation had more ICU-free time among all patients in univariable analysis (lowest early extubation group, 23.8 d [interquartile range, 18.2-25.9 d]; highest early extubation group, 24.7 d [20.0-26.2 d]; p < 0.001). After adjusting for center volume, sex, age, surgical complexity, and preoperative ICU admission, increasing center-level early extubation rates were not associated with more ICU-free days. Higher center-level early extubation rate was not associated with mortality in univariable or multivariable analysis but was associated with decreased extubation failure rate (lowest early extubation group, 6.4%; highest early extubation group, 3.6%; p < 0.001).
Conclusions:
In this large, multicenter database study, early extubation rates in postoperative cardiac patients did not significantly change between 2009 and 2018. Centers that performed early extubation more frequently did not have shorter ICU stays or difference in mortality rates but did have lower reintubation rates.
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