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Updated: Jul 15, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Risk Factors for Extubation Failure After Pediatric Cardiac Surgery and Impact on Outcomes: A Multicenter Analysis
Jonathan Byrnes1, David Bailly2, David K Werho3
1Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, AL.
Insights
Extubation failure (EF) in pediatric cardiac surgery increases mortality and length of stay. Identifying modifiable risk factors like intubation route and timing can help reduce EF rates.
Area of Science:
- Pediatric Cardiac Surgery
- Critical Care Medicine
- Extubation Management
Background:
- Extubation failure (EF) following pediatric cardiac surgery is a significant complication linked to increased morbidity and mortality.
- Understanding the distinct risk factors for early and late EF is crucial for improving patient outcomes.
Purpose of the Study:
- To identify risk factors for early (within 48 hours) and late (48-168 hours) extubation failure after pediatric cardiac surgery.
- To explore the clinical implications, including mortality and length of stay, associated with early and late EF.
Main Methods:
- Retrospective cohort study utilizing prospectively collected data from the Pediatric Cardiac Critical Care Consortium (PC4) Registry.
- Analysis included pediatric patients undergoing benchmark cardiac operations or heart transplants between 2013 and 2018.
- Demographics and risk factors for EF were analyzed, with a focus on potentially modifiable factors and clinical outcomes like mortality and length of stay (LOS).
Main Results:
- The study analyzed 18,278 extubations, with early EF rates at 5.2% and late EF at 2.5%.
- Cardiopulmonary bypass time, ventilator duration, airway anomalies, genetic abnormalities, pleural effusion, and diaphragm paralysis were associated with both early and late EF.
- Extubation during the day (away from shift change) and nasotracheal intubation decreased early EF risk, while operating room extubation increased early EF risk but decreased late EF risk.
Conclusions:
- Both early and late extubation failure significantly increase length of stay and mortality in pediatric cardiac surgery patients.
- The findings offer benchmarking data stratified by surgical type.
- Modifiable factors such as intubation route, extubation timing, and management of conditions like diaphragm paralysis or pleural effusion present opportunities for reducing EF.
Importance:
Extubation failure (EF) after pediatric cardiac surgery is associated with increased morbidity and mortality.
Objectives:
We sought to describe the risk factors associated with early (< 48 hr) and late (48 hr ≤ 168 hr) EF after pediatric cardiac surgery and the clinical implications of these two types of EF.
Design Setting And Participants:
Retrospective cohort study using prospectively collected clinical data for the Pediatric Cardiac Critical Care Consortium (PC4) Registry. Pediatric patients undergoing Society of Thoracic Surgeons benchmark operation or heart transplant between 2013 and 2018 available in the PC4 Registry were included.
Main Outcomes And Measures:
We analyzed demographics and risk factors associated with EFs (primary outcome) including by type of surgery. We identified potentially modifiable risk factors. Clinical outcomes of mortality and length of stay (LOS) were reported.
Results:
Overall 18,278 extubations were analyzed. Unplanned extubations were excluded from the analysis. The rate of early EF was 5.2% (948) and late EF was 2.5% (461). Cardiopulmonary bypass time, ventilator duration, airway anomaly, genetic abnormalities, pleural effusion, and diaphragm paralysis contributed to both early and late EF. Extubation during day remote from shift change and nasotracheal route of initial intubation was associated with decreased risk of early EF. Extubation in the operating room was associated with an increased risk of early EF but with decreased risk of late EF. Across all operations except arterial switch, EF portrayed an increased burden of LOS and mortality.
Conclusion And Relevance:
Both early and late EF are associated with significant increase in LOS and mortality. Study provides potential benchmarking data by type of surgery. Modifiable risk factors such as route of intubation, time of extubation as well as treatment of potential contributors such as diaphragm paralysis or pleural effusion can serve as focus areas for reducing EFs.
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