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      Early extubation after congenital heart surgery

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          Abstract

          Introduction:

          Despite recent advances in anesthesia, cardiopulmonary bypass and surgical techniques, children undergoing congenital heart surgery require postoperativemechanical ventilation. Early extubation was definedas ventilation shorter than 12 hours. Aim of this study is to identify factors associated with successful early extubation after pediatric cardiac surgery.

          Methods:

          The study was performed during period from January 2006 to January 2011 at Pediatric Clinic and Heart Center University Clinical center Sarajevo. One hundred children up to 5 years of age, who have had congenital heart disease, with left–right shunt and obstructive heart disease were included in the study. Patients were divided into two groups. Group I - patients extubated within 12 hours after surgery and Group II - patients extubated 12 or more hours after surgery.

          Results:

          The most frequently encountered preoperative variables were age with odds ratio 4% 95%CI (1-7%), Down’s syndrome 8.5 95%CI (1.6-43.15), failure to thrive 4.3 95%CI (1-18). Statistically significant postoperative data included lung disease (reactive airways, pneumonia, atelectasis, pneumothorax) and with odds ratio 35.1 95 %CI (4-286) and blood transfusion with odds ratio 4.6 95%CI (2-12). Blood transfusion (p=0.002) (Wald=9.2) 95%CI (2-12), during as well as after operation procedure has statistically significant influence on prediction time of extubation. Proven markers were age with cut of 21.5 months (sensitivity 74% and specificity 70%) and extracorporeal circulation (ECC) with cut-of 45.5 minutes (sensitivity 71% and specificity 65%).

          Conclusion:

          Early extubation is possible in many children undergoing congenital heart surgery. Younger age and prolonged ECC time are markers associated with prolonged mechanical ventilation.

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          Most cited references 20

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          Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease.

          Low cardiac output syndrome (LCOS), affecting up to 25% of neonates and young children after cardiac surgery, contributes to postoperative morbidity and mortality. This study evaluated the efficacy and safety of prophylactic milrinone in pediatric patients at high risk for developing LCOS. The study was a double-blind, placebo-controlled trial with 3 parallel groups (low dose, 25- microg/kg bolus over 60 minutes followed by a 0.25- microg/kg per min infusion for 35 hours; high dose, 75- microg/kg bolus followed by a 0.75- microg/kg per min infusion for 35 hours; or placebo). The composite end point of death or the development of LCOS was evaluated at 36 hours and up to 30 days after randomization. Among 238 treated patients, 25.9%, 17.5%, and 11.7% in the placebo, low-dose milrinone, and high-dose milrinone groups, respectively, developed LCOS in the first 36 hours after surgery. High-dose milrinone significantly reduced the risk the development of LCOS compared with placebo, with a relative risk reduction of 55% (P=0.023) in 238 treated patients and 64% (P=0.007) in 227 patients without major protocol violations. There were 2 deaths, both after infusion of study drug. The use of high-dose milrinone reduced the risk of the LCOS through the final visit by 48% (P=0.049). The use of high-dose milrinone after pediatric congenital heart surgery reduces the risk of LCOS.
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            Validation of predictors of extubation success and failure in mechanically ventilated infants and children.

            To validate predictors of extubation success and failure in mechanically ventilated infants and children by using bedside measures of respiratory function. Prospective, descriptive study. A university-affiliated children's hospital with a 51-bed critical care area. All infants and children who were mechanically ventilated for > or =24 hrs except neonates < or =37 wks gestation and patients with neuromuscular disease. None. Extubation failure was defined as reintubation within 48 hrs of extubation in the absence of upper airway obstruction. Failure rates were calculated for different ranges (selected a priori of preextubation measures of breathing effort, ventilator support, respiratory mechanics, central inspiratory drive, and integrated indices useful in adults. Effort of spontaneous breathing was assessed by the respiratory rate standardized to age, the presence of retractions and paradoxic breathing, inspiratory pressure, maximal negative inspiratory pressure, ratio of inspiratory pressure to maximal negative inspiratory pressure, and tidal volume indexed to body weight of a spontaneous breath. Ventilator support was measured by F(IO2), mean airway pressure, oxygenation index, and the fraction of total minute ventilation provided by the ventilator. Respiratory mechanics was assessed by peak ventilatory inspiratory pressure and dynamic compliance. Central inspiratory drive was assessed by mean inspiratory flow. Frequency to tidal volume ratio and the CROP (compliance, rate, oxygenation, and pressure) indexed to body weight, the integrated indices useful in predicting extubation failure in adults, were also calculated. A regression test for a linear trend in proportions was performed with preselected ranges and the corresponding failure rates. The failure rates from this study (validation group) were compared to those published previously (prediction group) by the chi-square test for proportions. The distribution of categorical variables between groups was analyzed by using the chi-square test or the Fisher's exact test, and p < .05 was considered significant. The study involved 312 patients. There were no differences in any of the clinical characteristics between the prediction and validation groups. The reasons for reintubation were similar in both groups. Preextubation data were also similar between the two groups. There were no differences between the prediction and the validation groups in failure rates with different ranges. There were no differences in the failure rates for any of the cutoff values for peak ventilatory inspiratory pressure, mean airway pressure, F(IO2), oxygenation index, dynamic compliance, tidal volume indexed to body weight of a spontaneous breath, fraction of total minute ventilation provided by the ventilator, and mean inspiratory flow. Bedside measures of respiratory function can predict extubation success and failure in infants and children. Both a low risk and a high risk of failure can be determined by using these measures. Integrated indices useful in adults do not reliably predict extubation success or failure in infants and children. Our study validates our previously published study.
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              Delay of extubation in neonates and children after cardiac surgery: impact of ventilator-associated pneumonia.

              This study was undertaken to determine the delay of extubation attributable to ventilator-associated pneumonia (VAP) in comparison to other complications and complexity of surgery after repair of congenital heart lesions in neonates and children. Cohort study in a pediatric intensive care unit of a tertiary referral center. All patients who had cardiac operations during a 22-month period and who survived surgery were eligible (n = 272, median age 1.3 years). Primary outcome was time to successful extubation. Primary variable of interest was VAP Surgical procedures were classified according to complexity. Cox proportional hazards models were calculated to adjust for confounding. Potential confounders comprised other known risk factors for delayed extubation. Median time to extubation was 3 days. VAP occurred in 26 patients (9.6%). The rate of VAP was not associated with complexity of surgery (P = 0.22), or cardiopulmonary bypass (P = 0.23). The adjusted analysis revealed as further factors associated with delayed extubation: other respiratory complications (n = 28, chylothorax, airway stenosis, diaphragm paresis), prolonged inotropic support (n = 48, 17.6%), and the need for secondary surgery (n = 51, 18.8%; e.g., re-operation, secondary closure of thorax). Older age promoted early extubation. The median delay of extubation attributable to VAP was 3.7 days (hazards ratio HR = 0.29, 95% CI 0.18-0.49), exceeding the effect size of secondary surgery (HR = 0.48) and other respiratory complications (HR = 0.50). VAP accounts for a major delay of extubation in pediatric cardiac surgery.
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                Author and article information

                Journal
                JHS
                Journal of Health Sciences
                University of Sarajevo Faculty of Health Studies (Bosnia )
                2232-7576
                1986-8049
                September 2014
                : 4
                : 3
                : 156-161
                Affiliations
                [1 ]Pediatric Clinic, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
                [2 ]Clinic for Cardiac surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
                Author notes
                [* ]Corresponding Author: Mirza Halimić, Pediatric clinic, University Clinical Center Sarajevo, Patriotske Lige 81, 71000 Sarajevo, Bosnia and Herzegovina. E-mail: halimicm@ 123456hotmail.com
                Article
                JHS-4-156
                Copyright: © Mirza Halimić

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Product
                Self URI (journal page): http://www.jhsci.ba/OJS/index.php/jhsci
                Categories
                RESEARCH ARTICLE

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