Factors Associated With Unplanned Post-Craniotomy Re-intubation in Children: A NSQIP-Pediatric ® Analysis

Most children undergoing craniotomy with general endotracheal anesthesia are extubated postoperatively, but some require unplanned postoperative intubation (UPI). We sought to determine the incidence of UPI and identify associated factors and related postoperative mortality.

The National Surgical Quality Improvement Program for Pediatrics (2012-2018) was used to retrospectively identify patients less than 18 years old who underwent craniotomy for epilepsy, tumor, and congenital/cyst procedures. Perioperative factors associated with UPI were identified with logistic regression models.

We identified 15,292 children, of whom 144 (0.94%) required UPI. Ninety-two (0.60%) children required UPI within the first 3 days after surgery. Postoperative mortality was higher among children with UPI within 3 days than in those with UPI later or not at all (8.0 vs. 2.2 vs. 0.3%, respectively; P <0.001). Posterior fossa procedures trended towards an increased odds of UPI (odds ratio [OR], 1.50; 95% confidence interval [CI] 0.99 to 2.27; P =0.05). Five preoperative factors were independently associated with UPI: age ≤ 12 months (OR, 2.78; 95% CI, 1.29 to 5.98), ASA classification ≥3 (OR, 1.92; 95% CI, 1.12 to 3.29), emergent case status (OR, 2.06; 95% CI, 1.30 to 3.26), neuromuscular disease (OR, 1.87; 95% CI, 1.01 to 3.47), and steroid use within 30 days (OR, 1.79; 95% CI 1.14 to 2.79). Long operative times were independently associated with UPI (200 to 400 vs. <200 min OR, 1.92; 95% CI 1.18 to 3.11 and ≥400 vs. <200 min OR, 4.66; 95% CI 2.70 to 8.03).

Although uncommon, UPI in children who underwent craniotomy was associated with an elevated risk of postoperative mortality. The presence of identifiable risk factors may be used for preoperative counseling and risk profiling in these patients.