title: Delay of extubation in neonates and children after cardiac surgery: impact of ventilator-associated pneumonia.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  VAP accounts for a major delay of extubation in pediatric cardiac surgery.
authors.affiliation: Department of Neonatology and Pediatric Intensive Care, University Children's Hospital, University of Zurich, Switzerland. joachim.fischer@kispi.unizh.ch
authors.forename: J E
authors.initials: JE
authors.lastname: Fischer
authors.forename: P
authors.initials: P
authors.lastname: Allen
authors.forename: S
authors.initials: S
authors.lastname: Fanconi
mesh_terms: D000704:Analysis of Variance; D006348:Cardiac Surgical Procedures; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D011014:Pneumonia / Q000209:etiology / Q000517:prevention & control*; D011183:Postoperative Complications / Q000517:prevention & control*; D016016:Proportional Hazards Models; D012121:Respiration, Artificial / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D013557:Switzerland; D013997:Time Factors