Effects of on-Table Extubation after Pediatric Cardiac Surgery

Abstract

Background: Enhanced recovery after surgery (ERAS) protocols are utilizing a multidisciplinary approach, reassessing physiology to improve clinical outcomes, reducing length of hospital stay (LOS) stay, resulting in cost reduction. Since its introduction in colorectal surgery. the concept has been utilized in various fields and benefits have been recognized also in adult cardiac surgery. However, ERAS concepts in pediatric cardiac surgery are not yet widely established. Therefore, the aim of the present study was to assess the effects of on-table extubation (OTE) after pediatric cardiac surgery compared to the standard approach of delayed extubation (DET) during intensive care treatment. Study Design and Methods: We performed a retrospective analysis of all pediatric cardiac surgery cases performed in children below the age of two years using cardiopulmonary bypass at our institution in 2021. Exclusion criteria were emergency and off pump surgeries as well as children already ventilated preoperatively. Results: OTE children were older (267.3 days vs. 126.7 days, p < 0.001), had a higher body weight (7.0 ± 1.6 kg vs. 4.9 ± 1.9 kg, p < 0.001), showed significantly reduced duration of ICU treatment (75.9 ± 56.8 h vs. 217.2 ± 211.4 h, p < 0.001) and LOS (11.1 ± 10.2 days vs. 20.1 ± 23.4 days; p = 0.001) compared to DET group. Furthermore, OTE children had significantly fewer catecholamine dependencies at 12-, 24-, 48-, and 72-h post-surgery, while DET children showed a significantly increased intrafluid shift relative to body weight (109.1 ± 82.0 mL/kg body weight vs. 63.0 ± 63.0 mL/kg body weight, p < 0.001). After propensity score matching considering age, weight, bypass duration, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STATS)-Score, and the outcome variables, including duration of ICU treatment, catecholamine dependencies, and hospital LOS, findings significantly favored the OTE group. Conclusion: Our results suggest that on-table extubation after pediatric cardiac surgery is feasible and in our cohort was associated with a favorable postoperative course.

Keywords: enhanced recovery after surgery (ERAS); on table extubation; pediatric cardiac anesthesia.

Figure 1

Population pyramid illustrates the distribution of patients in relation to (a) age (days of life); (b) body weight (kg); (c) height (cm). Blue bars represent delayed extubation group (DET) versus on-table extubation (OTE) green bars.

Figure 1

Population pyramid illustrates the distribution of patients in relation to (a) age (days of life); (b) body weight (kg); (c) height (cm). Blue bars represent delayed extubation group (DET) versus on-table extubation (OTE) green bars.

Figure 2

Perioperative fluid balance analysis revealed that the patients in the delayed extubation DET) group had significantly higher fluid shifts than the patients in the on-table extubation (OTE) group. In the diagram the mean fluid balance is shown. The columns represent the mean fluid balance at the time of end of surgery, 1st 2nd and 3rd postoperative day. Blue columns represent the DET group, green columns represent the OTE group. All differ significantly * p < 0.0001.

Figure 3

Mean vasoactive-inotropic score (VIS) in delayed extubation (DET) group (blue bars) and on-table extubation (OTE) group (green bars) preoperative, postoperative, 12 h postoperative, 48 h postoperative, 72 h postoperative. n.s. not significant, * p < 0.05, ** p <0.001.

Figure 4

Mean duration of catecholamine dependency, intensive care therapy LOS ICU), and length of hospital stay (LOS hospital) in delayed extubation (DET) group (blue bars) and on-table extubation (OTE) group (green bars). All differ significantly * p < 0.0001.

Figure 5

The distribution of cases according to the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STAT) category is shown. Blue columns represent the absolute number of cases in the DET group, the green columns represent the cases in the OTE group.

Figure 6

Duration of catecholamine dependency (p < 0.001), duration of intensive care therapy (p < 0.001), and length of hospital stay (p = 0.095) in delayed extubation DET group (blue bars) and on-table extubation OTE group (green bars) after propensity score matching, n.s. not significant, * p < 0.05.