Descriptors of Failed Extubation in Norwood Patients Using Physiologic Data Streaming

Area of Science:

• Neonatal physiology
• Pediatric cardiology
• Critical care medicine

Background:

• Neonates with hypoplastic left heart syndrome (HLHS) undergoing the Norwood procedure require careful management during extubation.
• Extubation failure can lead to significant morbidity and mortality in this vulnerable population.
• Predictive markers for extubation failure are essential for optimizing patient care.

Purpose of the Study:

• To evaluate the utility of high-frequency physiologic data and clinical variables in describing the physiologic profile of extubation failure in neonates with HLHS post-Norwood procedure.
• To identify key predictors of extubation failure in this specific patient group.

Main Methods:

• A single-center, retrospective analysis of extubation events in neonates with HLHS post-Norwood procedure from January 2016 to July 2021.
• Collected data included streaming heart rate, respiratory rate, blood pressure, arterial oxygen saturation, cerebral/renal near-infrared spectroscopy (NIRS), and pre-extubation laboratory results.
• Compared markers, demographics, clinical characteristics, and ventilatory settings between successful and failed extubations (re-intubation within 48 hours).

Main Results:

• The extubation failure rate was 10% among 311 extubations.
• Univariable analysis revealed failed extubations were preceded by higher respiratory rates, lower end-tidal CO2, lower pH, lower serum bicarbonate, and lower partial pressure of O2.
• Post-extubation, failed events showed lower arterial and cerebral NIRS saturations within 10 minutes and persistently lower cerebral NIRS at 2 hours.
• Multivariable analysis identified vocal cord anomaly, cerebral NIRS at 10 minutes post-extubation, renal NIRS (pre- and post-extubation), and pre-extubation end-tidal CO2 as significant predictors.

Conclusions:

• High-frequency physiologic data, particularly oximetric indices from near-infrared spectroscopy (NIRS) before, immediately after, and 2 hours post-extubation, are associated with failed extubation events in neonates with HLHS and parallel circulation.
• Vocal cord paralysis is also a significant predictor of extubation failure.
• These findings highlight the importance of continuous NIRS monitoring and assessment for vocal cord anomalies to improve extubation success rates in this population.