Postextubation Arterial Blood Gas to Predict Reintubation in Children With Congenital Heart Disease

Respiratory Care · 2026-02-24 · 2 citations

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 re-intubation. Conclusions: Eighty percent of subjects with postextubation acidemia did not require reintubation, but acidemia was associated with a 3-fold increased risk of reintubation.

Staged repair of borderline hypoplastic heart disease with early biventricular conversion

JTCVS Techniques · 2024-02-19 · 6 citations

Objective: In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular conversion by 2 years of age. Methods: Between 2018 and 2023, 14 newborns with borderline hypoplastic heart disease deemed high risk for primary biventricular repair underwent palliative procedures as a neonate/infant, followed by staged or direct biventricular conversion. Results: Of the 14 patients, 6 had borderline left ventricles and 8 had borderline right ventricles. Index neonatal operations were performed in 12 patients and included the Norwood operation (n = 5), pulmonary artery band (n = 3), ductal stent (n = 3), and hybrid Norwood (n = 1). Five patients underwent direct biventricular conversion, and the remaining 9 patients underwent staged ventricular recruitment operations at a mean age of 6 months (range, 3-11 months). Ventricular recruitment operations included atrial septation with or without ventricular rehabilitation, atrioventricular valve repair, or outflow tract operations. At a mean duration of 8 months (range, 4-10 months) after ventricular recruitment, there was a significant increase in chamber volume, aortic valve, and mitral valve size in patients with borderline left ventricles, and a normalization of the right ventricle:left ventricle end-diastolic volume ratio in patients with borderline right ventricles. To date, 13 of 14 patients have undergone successful biventricular conversion at a mean age of 16 months (range, 4-31 months). Conclusions: In select newborns with borderline hypoplastic heart disease, single-ventricle palliation followed by staged or direct biventricular conversion may increase infant survival while allowing for early attainment of a biventricular circulation.

Noninvasive Ventilation or CPAP in the Initial Treatment Phase of Small Infants With Respiratory Failure

Respiratory Care · 2024-07-16

Background: Respiratory failure in infants is a common reason for admission to the pediatric ICU (PICU). Although high-flow nasal cannula (HFNC) is the preferred first-line treatment at our institution, some infants require CPAP or noninvasive ventilation (NIV). Here we report our experience using CPAP/NIV in infants <10 kg. Methods: We conducted a retrospective review of infants <10 kg treated with CPAP/NIV in our PICUs between July 2017–May 2021 in the initial phase of treatment. Demographic, support type and settings, vital signs, pulse oximetry, and intubation data were extracted from the electronic health record. We compared subjects successfully treated with CPAP/NIV with those who required intubation. Results: We studied 62 subjects with median (interquartile range) age 96 [6.5–308] d and weight 4.5 (3.4–6.6) kg. Of these, 22 (35%) required intubation. There were no significant differences in demographics, medical history, primary interface, pre-CPAP/NIV support, and device used to deliver CPAP/NIV. HFNC was used in 57 (92%) subjects before escalation to CPAP/NIV. Subjects who failed CPAP/NIV were less likely to have bronchiolitis (27% vs 60%, P = .040), less likely to be discharged from the hospital to home (68% vs 93%, P = .02), had a longer median hospital length of stay (LOS) (26.9 [21–50.5] d vs 10.4 [5.6–28.4] d, P = .002), and longer median ICU LOS (14.6 [7.9–25.2] d vs 5.8 [3.8–12.4] d, P = .004). Initial vital signs and F IO 2 were similar, but S pO 2 was lower and F IO 2 higher at 6 h and 12 h after support initiation for subjects who failed CPAP/NIV. Initial CPAP/NIV settings were similar, but subjects who failed CPAP/NIV had higher maximum and final inspiratory/expiratory pressure. Conclusions: Most infants who failed initial HFNC support were successfully managed without intubation using NIV or CPAP. Bronchiolitis was associated with a lower rate of CPAP/NIV failure, whereas lower S pO 2 and higher F IO 2 levels were associated with higher rates of intubation.

Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery

World Journal for Pediatric and Congenital Heart Surgery · 2024-01-23 · 1 citations

Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite “textbook outcome” (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.

Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease

Respiratory Care · 2023-12-05 · 6 citations

BACKGROUND: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters. METHODS: Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist–driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success. RESULTS: A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6–6.5] months and median weight [interquartile range] 4.2 [3.3–6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mover accent="true"> <mml:mtext mathvariant="bold">P</mml:mtext> <mml:mo mathvariant="bold" stretchy="true">¯</mml:mo> </mml:mover> <mml:mtext mathvariant="bold">aw</mml:mtext> </mml:msub> </mml:mrow> </mml:math> ), and dead-space–to–tidal-volume ratio (all P &lt; .001) but not for <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mtext mathvariant="bold">F</mml:mtext> <mml:mrow> <mml:msub> <mml:mrow> <mml:mtext mathvariant="bold">IO</mml:mtext> </mml:mrow> <mml:mtext mathvariant="bold">2</mml:mtext> </mml:msub> </mml:mrow> </mml:msub> </mml:mrow> </mml:math> . ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mover accent="true"> <mml:mtext mathvariant="bold">P</mml:mtext> <mml:mo mathvariant="bold" stretchy="true">¯</mml:mo> </mml:mover> <mml:mtext mathvariant="bold">aw</mml:mtext> </mml:msub> </mml:mrow> </mml:math> , and dead-space–to–tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H 2 O, and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mover accent="true"> <mml:mtext mathvariant="bold">P</mml:mtext> <mml:mo mathvariant="bold" stretchy="true">¯</mml:mo> </mml:mover> <mml:mtext mathvariant="bold">aw</mml:mtext> </mml:msub> </mml:mrow> </mml:math> &gt; 10 cm H 2 O were associated with a decreased odds of ERT success, whereas children ages 1–5 years and an <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mtext mathvariant="bold">F</mml:mtext> <mml:mrow> <mml:msub> <mml:mrow> <mml:mtext mathvariant="bold">IO</mml:mtext> </mml:mrow> <mml:mtext mathvariant="bold">2</mml:mtext> </mml:msub> </mml:mrow> </mml:msub> </mml:mrow> </mml:math> of 0.31-0.40 had increased odds of ERT success. CONCLUSIONS: ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mover accent="true"> <mml:mtext mathvariant="bold">P</mml:mtext> <mml:mo mathvariant="bold" stretchy="true">¯</mml:mo> </mml:mover> <mml:mtext mathvariant="bold">aw</mml:mtext> </mml:msub> </mml:mrow> </mml:math> was associated with ERT success and that protocols should consider using <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" display="inline" overflow="scroll"> <mml:mrow> <mml:msub> <mml:mover accent="true"> <mml:mtext mathvariant="bold">P</mml:mtext> <mml:mo mathvariant="bold" stretchy="true">¯</mml:mo> </mml:mover> <mml:mtext mathvariant="bold">aw</mml:mtext> </mml:msub> </mml:mrow> </mml:math> instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.

679: NONINVASIVE VENTILATION OR CPAP IN HIGH-RISK SMALL INFANTS WITH RESPIRATORY DISTRESS IN THE PICU

Critical Care Medicine · 2023-12-14

Introduction: Respiratory distress in infants is a common reason for admission to the pediatric ICU. High-flow nasal cannula (HFNC) is first-line treatment at our institution, but some infants require noninvasive ventilation (NIV) or CPAP. This study aims to report our experience using NIV/CPAP in infants < 10 kg. Methods: We conducted a review of infants < 10 kg treated with NIV/CPAP July 1, 2017 and May 31, 2021 in our PICU and pediatric cardiac ICU, excluding those who received these modalities for post-extubation support. Demographic, medical history, support type and settings, vital signs, pulse oximetry, gas exchange, and reintubation data were extracted from the electronic health record. We compared successfully treated NIV/CPAP patients with intubated subjects using Chi-squared and Mann-Whitney tests for categorical and continuous data, respectively. Results: We studied 62 patients with median age 96 (6.5-308) days and weight 4.5 (3.4-6.6) kg. Of these, 22 (35%) required intubation. There were no significant differences in demographics, medical history, cardiac surgery need, primary interface, pre-NIV/CPAP support, device used to deliver NIV/CPAP, aerosolized medications delivered, and blood gases before initiation. We found that 57 (92%) received HFNC before NIV/CPAP. Intubated subjects were less likely to have bronchiolitis (27% vs 60%, P=0.04), less likely to be discharged from the hospital to home (68% vs 93%, P=0.02), had a longer median hospital LOS (26.9 [21.0-50.5] vs. 10.4 [5.6-28.4] days, P=0.002), longer median ICU LOS (14.6 [7.9-25.2] vs. 5.8 [3.8-12.4] days, P=0.004). Initial vital signs and FiO2 were similar, but SpO2 was lower and FiO2 higher at 6 and 12 hours after support initiation for patients who required intubation. Initial NIV settings were similar, but subjects who failed NIC/CPAP had higher maximum and final inspiratory/expiratory pressure. Conclusions: Most infants who failed initial HFNC support were successfully managed without intubation using NIV or CPAP. Bronchiolitis was associated with a lower rate of intubation, whereas lower SpO2 and higher FiO2 levels were associated with higher rates of intubation.

Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants

Respiratory Care · 2023-07-25 · 5 citations

BACKGROUND: Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs). METHODS: We performed a retrospective study of children &lt; 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables. RESULTS: We studied 51 subjects, median age 44 (interquartile range 0.5–242) d and weight 3.7 (3–4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH &lt; 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24–56] vs 62 [46–72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and F IO 2 were higher in subjects who required re-intubation. CONCLUSIONS: NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher F IO 2 , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.

Textbook outcome for the Norwood operation—an informative quality metric in congenital heart surgery

JTCVS Open · 2023-05-30 · 5 citations

Objectives: To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points.We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact.Methods: This was a single-center retrospective study of primary Norwood operations from 2005 to 2021.Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheterbased reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days).Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively.Results: Overall, 30% (58/196) of patients met the textbook outcome.Common reasons for failure to attain textbook outcome were prolonged ventilation (68/ 138, 49%) and reintubation (63/138, 46%).In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95;P .02)was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87;P .03)and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00;P .002)were negatively associated.Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], P < .001),and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89;P .02).Conclusions: Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric.The Norwood textbook outcome may represent a balanced measure of a successful episode of care.

Noninvasive Ventilation or CPAP for Post-Extubation Support in Small Infants

Respiratory Care · 2023-10-01

Background: Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs. Methods: We performed a retrospective study of children < 10 kg receiving post-extubation NIV or CPAP in our pediatric ICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and reintubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 hours of extubation. We compared successfully extubated and reintubated subjects using Chi-square for categorical variables and Mann-Whitney test for continuous variables. Results: We studied 51 subjects, median age 44 (IQR 0.5-242) days and weight 3.7 (3.0-4.9) kg. There were no demographic differences between groups, except those reintubated were more likely to have had cardiac surgery prior to admission (0% vs 14% P = .04). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%) while rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required reintubation. Reintubation rate was higher for rescue support (58% vs. 28%, P = .03). Subjects with a pH < 7.35 (4.3% vs 42%, P = .003) and lower somatic NIRS (39 [24-56] vs. 62 [46-72], P = .02) were more likely to be reintubated. The IPAP, EPAP, and FIO2 were higher in subjects who required reintubation. Conclusions: NIV or CPAP use was associated with a reintubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher FIO2, lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for reintubation.

696: FACTORS ASSOCIATED WITH SUCCESSFUL ERT IN CHILDREN WITH CONGENITAL HEART DISEASE

Critical Care Medicine · 2022-12-15

Introduction: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate mechanical ventilation liberation potential. There are minimal data suggesting what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with mechanical ventilator parameters. Methods: Data on daily ERT assessments were recorded as part of an IRB approved QI project. As part of our RT-driven ventilator protocol, patients are assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate differences in ventilator settings. The primary outcome was ERT success. ERT outcome was compared using the chi-square and Mann-Whitney test. Categorical data are reported as n (%), continuous data as median (interquartile range). Logistic regression was performed to evaluate factors associated with successful ERT and reported as odds ratio (OR). Results: We evaluated 780 ERTs from 320 subjects [median age 2.5 (0.6-6.5) months, 4.2 (3.3-6.9) kg]. 528 (68%) of ERTs were passed, 306 (58%) subjects were extubated after successful ERT and 30 (9.4%) were reintubated. There were significantly differences in ERT pass rate for ventilator mode (65% SIMV, 81% pressure support, 53% assist/control), PIP [17 (15-19) vs 19 (17-22) cmH2O], Δ pressure [12 (10-14) vs 14 (12-15) cmH2O], PEEP [5 (5-6) vs 6 (5-6) cmH2O], MAP [9 (8-10) vs 10 (9-11) cmH2O], and VD/VT [0.35 (0.28-0.42) vs 0.40 (0.33-0.46)] (all p< 0.001], but not for FiO2 [0.30 (0.21-0.40) vs 0.30 (0.23-0.35), p=0.14]. ERT success decreased with increases in PIP (87% ≤ 15 cmH2O, 66% 16-20 cmH2O, 50% 21-25 cmH2O, 27% 26-29 cmH2O), Δ pressure (85% ≤ 10 cmH2O, 63% 11-15 cmH2O, 51% 16-19 cmH2O, 22% ≥ 20 cmH2O), PEEP (73% ≤ 5 cmH2O, 63% 6 cmH2O, 42% 7 cmH2O), MAP (81% ≤ 8 cmH2O, 67% 9-10 cmH2O, 40% > 10 cmH2O, and VD/VT (75% < 0.30, 68% 0.31-0.40, 62% 0.41-0.50, 46% >0.50). Logistic regression revealed neonates, Δ pressure ≥11 cmH2O, and MAP > 10 cmH2O were associated with a decreased odds of ERT success while children aged 1-5 and an FiO2 0.31-0.40 had increased odds of ERT success. Conclusions: ERT pass rates decreased as ventilator support increased; however, some subjects passed ERT despite high ventilator support.