title: Factors affecting the decision to defer endotracheal extubation after surgery for congenital heart disease: a prospective observational study.
abstract: BACKGROUND
  Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR).
  
  
  METHODS
  We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites.
  
  
  RESULTS
  Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria.
  
  
  CONCLUSIONS
  Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.
authors.affiliation: Department of Anesthesiology, University of Tokyo, Tokyo, Japan.
authors.forename: Nobuhide
authors.initials: N
authors.lastname: Kin
authors.forename: Constance
authors.initials: C
authors.lastname: Weismann
authors.forename: Shubhika
authors.initials: S
authors.lastname: Srivastava
authors.forename: Sujata
authors.initials: S
authors.lastname: Chakravarti
authors.forename: Carol
authors.initials: C
authors.lastname: Bodian
authors.forename: Sabera
authors.initials: S
authors.lastname: Hossain
authors.forename: Marina
authors.initials: M
authors.lastname: Krol
authors.forename: Ingrid
authors.initials: I
authors.lastname: Hollinger
authors.forename: Khanh
authors.initials: K
authors.lastname: Nguyen
authors.forename: Alexander J C
authors.initials: AJ
authors.lastname: Mittnacht
mesh_terms: D000293:Adolescent; D000375:Aging / Q000502:physiology; D000701:Analgesics, Opioid; D000769:Anesthesia, Inhalation; D000778:Anesthetics, Dissociative; D018685:Anesthetics, Inhalation; D002315:Cardiopulmonary Bypass; D002648:Child; D002675:Child, Preschool; D004314:Down Syndrome / Q000150:complications; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal; D007530:Isoflurane; D007649:Ketamine; D008297:Male; D008738:Methyl Ethers; D009020:Morphine; D011446:Prospective Studies; D020379:Risk Adjustment; D012307:Risk Factors; D000077149:Sevoflurane
chemical_list: D000701:Analgesics, Opioid; D000778:Anesthetics, Dissociative; D018685:Anesthetics, Inhalation; D008738:Methyl Ethers; D000077149:Sevoflurane; D007649:Ketamine; D009020:Morphine; D007530:Isoflurane