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dvances in preoperative diagnosis, anesthesia, surgical techniques, and cardiopulmonary bypass have
enabled young children to benet from cardiac surgery,
even during the neonatal period [13]. Owing to the
progress in perioperative management, including fasttrack care, high rates of successful extubation [412],
short mechanical ventilation durations, and few complications [912] have been recently reported in select
pediatric cardiac patients, excluding those with complex
physiology and young infants. However, extubation failure (EF) in neonatal cardiac surgeries remains a signicant concern.
Extubation failure has been associated with longer
intensive care unit (ICU) stays, increased rates of complications, and greater mortality [1315]. Young age has
been reported as a risk factor for EF and prolonged mechanical ventilation [47, 15]. In recent studies [79, 12, 15],
EF in pediatric cardiac surgeries was rare (3% to 7%);
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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES
Setting
Shizuoka Childrens Hospital is an academic hospital
with 279 beds for children with complex diseases, and it is
a referral center for children with congenital heart
diseases. During the study period, 269 neonatal cardiac
surgeries were performed. All the children, except
premature neonates, were admitted to a 12-bed cardiac
ICU after surgery. Perioperative intensive care was
provided by six pediatric intensivists 24 hours a day.
Statistical Analysis
For the patient characteristics, continuous variables are
presented as median (interquartile range), and categoric
variables are presented as number (percentage). We
compared baseline patient characteristics, operative data,
and perioperative data using Fishers exact test or
Students t test for categoric and continuous variables,
respectively. The variables in the bivariate analyses
included age at surgery, sex, underlying background,
mechanical ventilation before surgery, prolonged
duration of mechanical ventilation, delayed sternal
closure, extracorporeal membrane oxygenation use,
preextubation sedation score, presence of a single
ventricle, cyanotic physiology, STAT score, nitric oxide
use, steroid use, and postoperative complications.
Multiple logistic regression models were used to obtain
adjusted odds ratio and 95% condence interval, with EF
as the outcome variable. We included the variables that
were signicantly different between groups in the bivariate comparison or considered clinically relevant. In the
bivariate analysis, continuous variables were converted
into categoric variables with quartiles or based on
categories used in previous reports. All statistical analyses were performed using R software, version 3.2.1
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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES
Results
During the study period, 269 neonatal cardiac surgeries
were performed. After the exclusion of cases who were
admitted to the NICU (n 69), did not undergo an
extubation attempt (n 22), or the second surgery within
the neonatal period (n 22), the study included 156 cases.
The median age at surgery was 10 days (range, 0 to 30),
and the median body weight was 2.9 kg (range, 1.7 to
3.8 kg). The baseline characteristics and surgical variables
are presented in Table 1. The median duration of mechanical ventilation after surgery was 5 days (range, 3 to 8).
Extubation failure occurred in 25 extubations (16.0%; 95%
condence interval: 10.6% to 22.7%). The most common
etiology was respiratory dysfunction (n 16), followed by
hemodynamic instability (n 4), upper airway obstruction
(n 4), and gastrointestinal bleeding (n 1).
Among the 16 cases who had EF due to respiratory
dysfunction, signicant hypoxia was noted in 5 cases,
worsening hypercarbia was noted in 5 cases, and significant respiratory effort was noted in 12 cases. With
multilateral diagnostic assessments for respiratory issues,
the diverse causes were identied in detail (Table 2). All
4 cases of upper airway obstruction needed intubation
within 1 hour after extubation. Among the 25 failed cases,
Table 1. Baseline Characteristics and Surgical Variables
(n 156)
Characteristics
Age at surgery, days
Male
Body weight, kg
Prematurity, <36 weeks
Chromosomal abnormality
Mechanical ventilation before surgery
Single-ventricle physiology
Corrective repair
Palliative procedure
Blalock-Taussig shunt
RV-PA conduit
Pulmonary artery banding
STAT mortality category
2
3
4
5
Use of cardiopulmonary bypass
Cardiopulmonary bypass time, minutes
Aortic cross-clamp time, minutes
Deep hypothermic circulation arrest
10
99
2.9
6
24
41
63
62
94
30
7
50
(417)
(63)
(2.53.2)
(4)
(15)
(26)
(40)
(40)
(60)
(19)
(4)
(32)
14
24
105
13
101
171
75
8
(9)
(15)
(67)
(8)
(65)
(132213)
(5296)
(5)
Comment
The present study found that the prevalence of EF was
16.0% (25 of 156); the most common etiology of EF was
respiratory dysfunction (n 16), followed by hemodynamic instability (n 4), upper airway disease (n 4),
and gastrointestinal bleeding (n 1); and the independent risk factors for EF were airway diseases and
prolonged mechanical ventilation. This study contributes
to our comprehensive knowledge of EF in neonatal
cardiac surgery, as previous studies excluded neonates,
palliative surgery cases, or children who had been intubated previously. Moreover, this is the rst study to
investigate the etiologies for each case with EF in detail.
The EF prevalence of 16.0% in our study is relatively
high when compared with the recently reported EF
prevalence of 3% to 7% among children after cardiac
surgery [79, 12, 15]. This difference in the EF prevalence
might have resulted from our study being focused on the
neonatal population. Thaiagrajan and colleagues [18]
reported EF rates of 21% in neonates, 9% in infants and
children. Neonates possess anatomic and physiologic
features that increase the possibility of EF. Some of the
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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES
Table 2. Causes of 25 Cases of Failed Extubation, Subsequent Extubation, and Surgical Reintervention
Causes of Failure
Respiratory dysfunction
Diaphragmatic paralysis
Atelectasis
Malacia
Tracheal stenosis
Weak cough
Pleural effusion
Pneumothorax
Respiratory muscle weakness
Pulmonary congestion
GERD
Hemodynamic instability
Low output syndrome
Onset of sepsis
Upper airway obstruction
Excessive secretion
Vocal cord paralysis
Glossoptosis
Gastrointestinal bleeding
a
Number of Cases
Surgical Reintervention
(n 16)
3
3
2
1
2
1
1
1
1
1
(n 4)
3
1
(n 4)
2
1
1
1
(n 12)
2
2
1
1
1
1
1
1
1
1
(n 2)
1
1
(n 2)
1
1
0
1
(n 4)
1 tracheostomy
1 cardiac surgery
1 tracheostomy
0
1 tracheostomy
0
0
0
0
0
(n 2)
1 cardiac surgery, 1 ECPR
0
(n 2)
1 cardiac surgery
0
1 cardiac surgery
0
Cases with successful extubation after initial extubation failure without any surgical intervention.
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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES
Variables
Demographics and
comorbidities
Age at surgery <4 days
Male
Body weight <2.47 kg
Chromosomal
abnormality
MV before surgery
Airway diseases
Lung diseases
Single-ventricle
physiology
Intraoperative
Palliative procedure
STAT mortality score
>1.9
CPB time >183 minutes
Aortic cross-clamp time
>81 minutes
Deep hypothermic
circulatory arrest
Postoperative
MV after surgery >7 days
Nitric oxide use
Delayed sternal closure
ECMO use
Diaphragmatic paralysis
Periextubation
Cyanotic physiology
Steroid use
Preextubation sedation
score >12
Extubation
Success
(n 131)
p
Value
12
17
5
5
(48)
(68)
(20)
(20)
23
82
37
19
(18)
(63)
(28)
(15)
0.003
0.66
0.62
0.55
11
8
1
12
(44)
(32)
(4)
(48)
30
5
3
51
(23)
(4)
(2)
(39)
0.04
<0.001
0.51
0.51
18 (72)
9 (36)
76 (58)
29 (22)
0.27
0.20
8 (32)
5 (20)
31 (24)
34 (26)
0.45
0.62
3 (12)
5 (4)
0.12
18
12
13
2
3
(72)
(48)
(52)
(8)
(12)
18 (72)
22 (88)
4 (16)
28
49
29
2
6
(21)
(37)
(22)
(2)
(5)
66 (50)
105 (80)
35 (27)
<0.001
0.37
<0.001
0.12
0.16
0.05
0.58
0.32
p Value
18.2 (3.888.6)
8.2 (1.934.9)
0.0003
0.0046
MV mechanical ventilation;
OR
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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES
10.
11.
12.
13.
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15.
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17.
18.
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22.
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