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ABSTRACT: OBJECTIVE: The objective of the study was to identify incidence, aetiology, and outcomes of extubation failure in infants with shunt-dependent pulmonary blood flow at a single tertiary care, academic children's hospital. The second objective of this study was to determine the haemodynamic effects of transition of positive pressure ventilation to spontaneous breathing in infants with extubation failure. Patients and methods Extubation failure for our study was defined as the need for positive pressure ventilation within 96 hours after extubation. We collected demographics, pre-operative, intra-operative, post-operative, and peri-extubation data in a retrospective, observational format in patients who underwent a modified Blalock-Taussig shunt between January, 2005 and March, 2011. Infants undergoing Norwood operation or Damus-Kaye-Stansel with modified Blalock-Taussig shunt were excluded from the study. The cardiorespiratory variables collected before extubation and immediately after extubation included heart rate, respiratory rate, mean arterial blood pressure, central venous pressures, near infrared spectroscopy, oxygen saturations, and lactate levels. Clinical outcomes evaluated included the success or failure of extubation, cardiovascular intensive care unit length of stay, hospital length of stay, and mortality. Descriptive and univariate statistics were utilised to compare groups with extubation failure and extubation success. RESULTS: Of the 55 eligible patients during the study period, extubation failure occurred in 27% (15/55) of the patients. Of the 15 patients with extubation failure, 10 patients needed reintubation and five patients received continuous positive pressure ventilation without getting reintubated. There were three patients who had extubation failure in the first 2 hours after extubation, nine patients in the 2-24-hour period, and three patients in the 24-96-hour period. In all, eight patients were extubated in the second attempt after the first extubation failure, with a median duration of mechanical ventilation of 2 days (1 day, 6 days). The median age of patients at extubation was 19 days (12 days, 22 days) and median weight of patients was 3.6 kg (3.02 kg, 4.26 kg). In all, 38% (21/55) of the patients were intubated before surgery. The most common risk factors for failed extubation were lung disease in 46% (7/15), cardiac dysfunction in 26% (4/15), diaphragmatic paralysis in 13% (2/15), airway oedema in 6% (1/15), and vocal cord paralysis in 6% (1/15). The median duration of mechanical ventilation was 4 days (1 day, 10.5 days), median cardiovascular intensive care unit length of stay was 11 days (6.5 days, 23.5 days), and the median hospital length of stay was 30 days (14 days, 48 days). The overall mortality at the time of hospital discharge was 7%. CONCLUSIONS: Extubation failure in infants with shunt-dependent pulmonary blood flow and univentricular physiology is high and aetiology is diverse. Cardiopulmonary effects of removal of positive pressure ventilation are more pronounced in children with extubation failure and include escalation in the need for oxygen requirement and increase in mean arterial blood pressure. The majority of extubation failures in this select patient population occurs in the first 24 hours. Extubation failure in these patients is not associated with increased hospital length of stay or mortality.
Cardiology in the Young 01/2013; · 0.76 Impact Factor
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Rachel McDonald,
Andrew Dodgen,
Sunali Goyal,
Jeffrey M Gossett,
Takeshi Shinkawa,
Santosh C Uppu,
Carlos Blanco,
Xiomara Garcia,
Adnan T Bhutta,
Michiaki Imamura,
Punkaj Gupta
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ABSTRACT: The primary objective of this study was to describe the impact of 22q11.2 deletion (del22q11) on the clinical characteristics, postoperative course, and short-term outcomes of children undergoing surgery for congenital heart disease. The charts of all children ages 1 day-18 years who received cardiac surgery for interrupted aortic arch (IAA), tetralogy of Fallot (TOF), or truncus arteriosus (TA) repair from 1 January 2001 to 31 December 2011 were retrospectively reviewed. The patients were divided into two groups: the 22q11 group including children with del22q11 undergoing surgery for TOF, IAA, or TA and the non-22q11 or control group including children with no chromosomal or genetic abnormality undergoing surgery for TOF, IAA, or TA. Demographic information, cardiac diagnoses, noncardiac abnormalities, preoperative factors, intraoperative details, surgical procedures performed, postoperative complications, and in-hospital deaths were collected. The outcome data collected included days of inotrope use, need for dialysis, length of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. The study enrolled 173 patients: 65 patients in the 22q11 group and 108 patients in the control group. Of the 65 patients in the 22q11 group, 36 (55 %) underwent repair for TOF, 13 (20 %) for IAA, and 16 (25 %) for TA. The two groups did not differ in terms of age or weight. The preexisting conditions were similar in the two groups. Unplanned noncardiac operations were more common in the children with del22q11, but delayed chest closure was similar in the two groups. The incidence of postoperative noncardiac complications such as reintubation, vocal cord paralysis, and diaphragmatic paralysis was similar in the two groups. However, increasing numbers of patients in del22q11 group needed dialysis in one form or the other during the immediate postoperative stay. The incidence of fungal infection and wound infection was higher in the del22q11 group than in the control group. Duration of mechanical ventilation, ICU LOS, and hospital LOS were similar in the two groups, except in certain subgroups. Mortality did not differ significantly between the two groups. In conclusion, children with del22q11 have a higher risk of postoperative complications after cardiac surgery, with no difference in length of mechanical ventilation, ICU LOS, hospital LOS, or mortality. However, short-term outcomes may differ in certain subgroups.
Pediatric Cardiology 08/2012; · 1.30 Impact Factor
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ABSTRACT: Identify incidence, etiology, and predictors of extubation failure in neonates and infants who underwent Norwood operation with either a modified Blalock-Taussig shunt (mBTS) or a Sano shunt at a single tertiary care, academic children's hospital.
Extubation failure for our study was defined as reintubation within 96 hours after extubation. We collected demographics, preoperative, intraoperative, postoperative, and peri-extubation data in a retrospective, observational format in patients who underwent Norwood operation with either a modified Blalock-Taussig shunt (mBTS) or a Sano shunt between January 2005 and March 2011. Clinical outcomes evaluated included the success or failure of extubation, cardiac intensive care unit (CICU) length of stay (LOS), hospital LOS, and mortality. Descriptive, univariate, and multivariate statistics were utilized to compare groups with extubation failure and extubation success.
Of 64 eligible patients during the study period, extubation failure occurred in 22% (14 of 64) of the patients. Eight patients failed extubation in the first 24 hours with an extubation failure rate of 12%. The median age of patients was 18 days (range 13.75 days to 22 days) and median weight of patients was 3.37 kg (range 3.11 kg to 3.86 kg). Twelve patients received a mBTS while 52 patients received a Sano shunt. All extubation failures occurred in patients receiving a Sano shunt. The most common risk factors for failed extubation were lung disease in 29% (4 of 14), cardiac dysfunction in 21% (3 of 14), diaphragmatic paralysis in 14% (2 of 14), airway edema in 14% (2 of 14), vocal cord paralysis in 14% (2 of 14), and laryngotracheomalacia in 7% (1 of 14). Patients with extubation failure had longer CICU LOS and hospital LOS. Overall mortality at the time of hospital discharge was 8%. Independent predictors of extubation failure included use of nitric oxide after surgery, increased days of mechanical ventilation prior to extubation, elevated inotrope score leaving the operating room, and presence of atelectasis prior to extubation.
Extubation failure in children after the Norwood operation is a slow and evolving process occurring as late as 96 hours after extubation and is not associated with an increase in in-hospital mortality. Causes of failed extubation are diverse. Successful weaning from positive pressure ventilation depends on adequate cardiovascular function, the presence of satisfactory ventilatory reserves, and favorable pulmonary mechanics.
The Annals of thoracic surgery 07/2012; 94(4):1262-8. · 3.74 Impact Factor
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ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for life-threatening respiratory or circulatory failure. Although outcomes are favorable with short-term ECMO therapy, data on the outcomes of prolonged ECMO therapy in children are very limited. This study aimed to study morbidity and mortality associated with prolonged ECMO therapy (≥28 days) in children with refractory cardiac or pulmonary failure.
We conducted a retrospective review of all children≤18 years supported with ECMO for ≥28 days between January 1991 and September 2011 at the Arkansas Children's Hospital. The data collected in our study included patient demographic information; diagnosis; indication for ECMO; ECMO support details; medical and surgical history; laboratory, microbiologic, and radiographic data; information on organ dysfunction; complications; and patient outcomes. The outcome variables evaluated in this report included survival to ECMO decannulation, survival to hospital discharge, and current survival with emphasis on neurologic, renal, pulmonary, and other end organ function.
During the study period, 984 events in 951 patients were supported with ECMO with a 30-day survival of 666 events (68%). Only 22 ECMO runs were ≥28 days and were eligible for inclusion in this report. The longest ECMO run in our series was 1,206 hours (50 days). The average length of ECMO run in this cohort was 855±133 hours, with a mean intensive care unit length of stay of 56±27 days. Ten patients (45%) were successfully decannulated from ECMO. Six patients (27%) were alive 30 days after decannulation, and only 4 patients (19%) survived to hospital discharge. Of the 4 survivors, only 3 patients (14%) are living to date. Of the 3 living children, 2 have significant neurologic issues with brain atrophy and developmental delay, and 1 is awaiting renal transplant; all 3 survivors have chronic lung disease.
This case series highlights that the prolonged use of ECMO in children with refractory cardiac failure, respiratory failure, or both is associated with low survival. Furthermore, it suggests that the survivors of prolonged ECMO runs have significant long-term sequelae.
The Annals of thoracic surgery 03/2012; 93(5):1584-90. · 3.74 Impact Factor
