Extubation failure after cardiac surgery in children with Down syndrome.
Salgado F, Larios G, Valenzuela G, Amstein R, Valle P, Valderrama P.Eur J Pediatr. 2023 Jul;182(7):3157-3164. doi: 10.1007/s00431-023-04946-w. Epub 2023 Apr 26.PMID: 37186033
Guest Editors:
Jamie Sinton MD, Cincinnati Children’s Hospital, Cincinnati, OH
Rajeev Wadia MD, University of California, Davis, CA
Take Home Points:
- In children with Down syndrome, extubation failure following cardiac surgery is associated with younger age, presence of aortic coarctation, severe hypotonia and presence of an increased cardiothoracic ratio.
Extubation failure (EF) after cardiac surgery is associated with severe morbidities such as increases in intensive care unit length of stay, mechanical ventilation, infections, respiratory complications, and mortality. Consequently, the results of this single-center retrospective case-control study by Salgado and colleagues are important [1]. The study objective was to describe the frequency of EF among infants with Down syndrome (DS) following cardiac surgery and determine risk factors for EF in this group. The cases (EFs) were matched 1:1 with controls on age, sex, and type of congenital heart disease. Following matching, risk factors for extubation failure were younger age, aortic coarctation, higher cardiothoracic ratio (CTR), and hypotonia.
True predictors of EF in children with DS require further study; however, the predictors listed in this manuscript build on previous published risk factors for failed extubation [2] but concentrate on children with Down syndrome. The risk factors presented in this study are largely non-modifiable. A search for modifiable risk factors that incorporate preoperative airway obstruction status, and intraoperative medication receipt would be more actionable.
The authors studied a wide range of time over which practice shifts occurred and did not account for era differences. Early extubation, within six hours of arrival to the ICU (2016 Mahle)[3] though in the United States, the introduction of sugammadex off-label in pediatric anesthesia (2017 Liu), and extubation to high flow nasal cannula either primarily or for rescue (2021 Stevens) [4] became common during the study period. The impact of these practice changes is less clear. Prospective data collection on preoperative airway evaluation, atelectasis by lung ultrasound, assurance of adequacy of reversal of neuromuscular blockade (critical given the possibility of post-bypass renal insufficiency), and more detailed medication and airway management would be an appropriate next step. The use of cardiothoracic ratio on chest roentgenogram to define severe hypotonia could be confounded by cardiac pathology that would alter the cardiothoracic ratio. This measurement is less functional, not measured separately from weakness (that may or may not coexist with hypotonia), and therefore may not be generalizable outside the study.
Risk factors associated with EF and the etiology of EF in infants with DS require further investigation. Specifically, the authors speculate that the cumulative exposure to sedoanalgesics, and neuromuscular blockade was greater in the EF group. These are modifiable risk factors that could be prospectively investigated. Additionally, coarctation of the aorta, if repaired by thoracotomy, presents intercostal muscle trespass and is an unfair comparison to other lesions repaired by sternotomy. Approximately half of children with Down syndrome have congenital heart disease. Upper airway obstruction and Down syndrome, which often coexist, are risk factors for EF following congenital heart surgery (2017 Miura) [5].
The objective of this study was to describe the frequency and risk factors for EF in infants with Down syndrome status post heart surgery. Extubation failure was defined as reintubation within 48 to 72 hours after extubation. No time course was available for initial extubation. Further details regarding surgical approach, mechanical ventilation, and modifiable aspects of care may lead to improved extubation success.
Risk factors for extubation failure did not differ from prior works in infants without Down syndrome (2017 Miura, 2019 Rooney) [5, 6]. The preoperative degree of upper airway obstruction or respiratory support (other than “chronic mechanical ventilation”) were not reported. One could also conclude that assessment of hypotonia as it relates to breathing was absent though CTR was a reasonable surrogate.
Extubation success after cardiac surgery is vital to improving outcomes, especially in high-risk infants such as those with Down syndrome. The frequency and risk factors for EF appear to be minimally modifiable based on the findings of this paper. A search for modifiable risk factors with airway and medication details would have been relevant to this discussion.
This article provides a basis for the study of extubation failure in infants with Down syndrome status post heart surgery. Future studies could incorporate prospective methods with increased granularity of detail regarding preoperative airway obstruction such as a diagnosis of obstructive sleep apnea, sedoanalgesic medications, timing, dose, and recovery from neuromuscular blockade.
References
1. Salgado, F., et al., Extubation failure after cardiac surgery in children with Down syndrome. Eur J Pediatr, 2023. 182(7): p. 3157-3164.
2. Gaies, M., et al., Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium. Pediatr Crit Care Med, 2015. 16(9): p. 837-45.
3. Mahle, W.T., et al., Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med, 2016. 17(10): p. 939-947.
4. Stevens, H., et al., Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study. J Pediatr Intensive Care, 2023. 12(3): p. 167-172.
5. Miura, S., et al., Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk Factors. Ann Thorac Surg, 2017. 103(4): p. 1293-1298.
6. Rooney, S.R., et al., Extubation Failure Rates After Pediatric Cardiac Surgery Vary Across Hospitals. Pediatr Crit Care Med, 2019. 20(5): p. 450-456.
- Liu, G., Wang, R., Yan, Y. et al. The efficacy and safety of sugammadex for reversing postoperative residual neuromuscular blockade in pediatric patients: A systematic review. Sci Rep 7, 5724 (2017). https://doi.org/10.1038/s41598-017-06159-2