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Postextubation Arterial Blood Gas to Predict Reintubation in Children With Congenital Heart Disease
Andrew G Miller1,2,3, Katherine Cashen1, Elizabeth J Thompson1,4
1Mr. Miller, Dr. Cashen, Dr. Thompson, Dr. Zakhar, Dr. Allareddy, and Dr. Rotta are affiliated with the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA.
Insights
Postextubation acidemia in children with cardiac disease increases reintubation risk threefold. While most children do not require reintubation, monitoring acid-base balance is crucial for pediatric cardiac intensive care unit patients.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Respiratory Physiology
Background:
- Mechanical ventilation is common in children with cardiac disease.
- Arterial blood gas (ABG) analysis postextubation is standard practice.
- Limited data exist on the utility of postextubation ABGs in this population.
Purpose of the Study:
- To investigate the association between postextubation acidemia and reintubation in pediatric cardiac patients.
- To identify factors associated with reintubation after mechanical ventilation.
Main Methods:
- Retrospective evaluation of 718 patients in a pediatric cardiac intensive care unit (PCICU) between June 2022 and December 2024.
- Definition of acidemia as arterial pH <7.35.
- Primary outcome: reintubation within 48 hours; secondary outcomes: duration of noninvasive respiratory support (NRS) and hospital stay.
Main Results:
- Acidemia was present in 13% of subjects (91/718).
- Subjects with acidemia had a higher likelihood of reintubation (21% vs 7.3%) and longer NRS duration.
- Factors associated with reintubation included acidemia (OR 2.8), ventricular assist device placement (OR 30.2), and higher extubation readiness test (ERT) breathing frequency (OR 1.03).
Conclusions:
- Postextubation acidemia is associated with a threefold increased risk of reintubation in children with cardiac disease.
- Despite the increased risk, 80% of subjects with acidemia did not require reintubation.
Background:
Children with cardiac disease frequently receive mechanical ventilation. Drawing an arterial blood gas (ABG) 1-2 h postextubation is common practice. Limited data exist evaluating the utility of ABGs in this context. We hypothesized that postextubation acidemia would be associated with reintubation.
Methods:
We retrospectively evaluated all patients with an ABG postextubation in the pediatric cardiac intensive care unit (PCICU) between June 2022 and December 2024. We defined acidemia as an arterial pH <7.35. Our primary outcome was reintubation within 48 h. Secondary outcomes included duration of noninvasive respiratory support (NRS) and hospital stay.
Results:
We studied 718 subjects, and 91 (13%) had acidemia. Subjects with postextubation acidemia were more likely to be reintubated (21% vs 7.3%, P < .001) and spent longer on NRS (6.7 [2.8-15.9] vs 4.6 [2.2-10.9] days, P = .036). Hospital and PCICU stay were similar. Prior to extubation, demographics, medical history, and surgical history showed no differences, except subjects with acidemia more frequently had delayed sternal closure (34% vs 20%, P = .007) and single ventricle physiology (40% vs 27%, P = .009). Pre-extubation variables were similar between groups. Subjects with acidemia had higher median pre-extubation 24-h fluid balance, higher median 48-h fluid balance, higher final extubation readiness test (ERT) breathing frequency (39 [32-47] vs 35 [26-44] breaths/min, P = .01), lower final ERT tidal volume (6.7 [5.4-7.6] vs 7.1 [6.0-8.3] mL/kg, P = .004), more frequent upper airway obstruction (26% vs 9.4%, P < .001), and required higher NRS at 24, 48, and 72 h after extubation. Logistic regression identified acidemia (odds ratio [OR] 2.8, 95% CI [1.4-5.6], P = .004), ventricular assist device placement (OR 30.2, 95% CI [2.3-396.9], P = .009), and final ERT breathing frequency (OR 1.03, 95% CI [1.01-1.06], P = .006) as factors associated with reintubation.
Conclusions:
Eighty percent of subjects with postextubation acidemia did not require reintubation, but acidemia was associated with a 3-fold increased risk of reintubation.
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