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Immediate Extubation In The Operating Room After Pediatric Cardiac Surgery; Its Incidence And Risk Factor For Reintubation
Takeshi Shinkawa, Jessica Holloway, Xinyu Tang, Jeffrey M Gossett, Rahul Dasgupta, Michael L Schmitz, Michiaki Imamura
Arkansas Children's Hospital, Little Rock, AR

OBJECTIVES:
The objectives of this study were to access the incidence of immediate endotracheal extubation in the operating room after pediatric cardiac surgery and the factors associated with immediate extubation, and to investigate risk factors for reintubation after immediate extubation at a single institution.
METHODS:
This is a retrospective study for all patients who had cardiac surgery with cardiopulmonary bypass from January 2011 through June 2016 at a single institution. Patients who were intubated preoperatively and who had an open sternum or mechanical circulatory support postoperatively were excluded since they were not candidate for immediate extubation. Risk factor analysis for reintubation after immediate extubation was performed only for a subset of patients who underwent the stage II palliation (Glenn or Hemi-Fontan operation) for single ventricle physiology.
RESULTS:
Nine hundred and nine patients who were candidates for immediate extubation in the operating room were identified. Immediate extubation was performed in 591 patients (65.0%), and the incidence of immediate extubation increased during the study period in all age groups. A multiple logistic regression model showed that surgeries performed in more recent years (p<0.001), shorter cardiopulmonary bypass times (p<0.001), shorter aortic cross clamp times (p=0.008), and lower STAT scores (p<0.001) were significantly associated with immediate extubation. The identities of the surgeon (p=0.041) and the anesthesiologists (p<0.001) were also associated with immediate extubation. Reintubation in the intensive care unit was performed for 37 patients among 591 immediate extubation patients (6.3%), significantly less frequent reintubation rate when compared to those without immediate extubation (49 patients among 320 non-immediate extubation patients, 15.3%; p<0.001). Between patients with reintubation after immediate extubation and those without in the stage II palliation, there were significant differences in age (0.4 vs. 0.5 years, p=0.044), pO2/FiO2 at the last blood gas analysis (suggestive of lung injury, 66 vs. 98 mmHg, p=0.032), pO2 at last blood gas analysis (39 vs. 47 mmHg, p=0.008), inotropic score (4 vs. 0, p=0.014), and intraoperative packed red blood cell use (420 vs. 334 ml, p=0.006). A univariate analysis showed that younger age (p=0.061), higher inotropic score (p=0.056), and lower pO2/FiO2 (p=0.032) were associated with reintubation after immediate extubation in univariate model, and only younger age (p=0.042) was associated in multivariable model.
CONCLUSIONS:
Immediate tracheal extubation in the operating room after pediatric cardiac surgery with cardiopulmonary bypass can be performed safely in many patients. Age is a predictor for reintubation after immediate extubation in the stage II palliation for patients with single ventricle physiology.


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