title: Extubation in the operating room after cardiac surgery in children: a prospective observational study with multidisciplinary coordinated approach.
abstract: OBJECTIVE
  This prospective observational study was undertaken to determine the feasibility of extubation of children in the operating room after cardiac surgery.
  
  
  METHODS
  A prospective observational study compared with historic controls.
  
  
  METHODS
  A single tertiary care referral hospital.
  
  
  METHODS
  One thousand consecutive pediatric patients requiring cardiac surgery aged 1 day to 18 years. Patients with spinal deformity, neurologic problems, coagulopathy as diagnosed by high international normalized ratio (INR) more than 1.5, and patients preoperatively on mechanical ventilation were excluded from the study. Data were also reviewed for another 1,000 patients operated before the beginning of this study, which constituted historic controls.
  
  
  METHODS
  All 1,000 patients were considered as potential candidates for extubation in the operating room after cardiac surgery and managed by a combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine, and extubation in the operating room was attempted after completion of the surgical procedure. These comprised the study group (SG). Data also were reviewed for another 1,000 patients before the beginning of this study when extubation in the operating room was not attempted and compared with this group to study the impact of extubation in the operating room on intensive care unit (ICU) stay and resource utilization. This data comprised the before-study group (BSG).
  
  
  RESULTS
  Eight hundred seventy-one (87.1%) patients were extubated in the operating room. This included 40% of neonates and 70%, 85%, and 91% of patients aged between 1 and 3 months, 3 months to 1 year, and more than 1 year, respectively. Forty-five patients (4.5%) required re-intubation within 24 hours, and 9 patients died among those extubated in the OR, but for reasons thought not to be related to extubation. The ICU stay was significantly less in the study group (2.56±1.84 v 5.4±2.32 days, p<0.0001) as compared to before-study group (BSG). The number of patients in the ICU (34.76±3.19 v 59.98±4.92, p<0.0001) and the number of patients on a ventilator (5.1±1.24 v 24.5±2.88, p<0.0001) on a daily basis were significantly less in the study group, reflecting positive impact on resource utilization.
  
  
  CONCLUSIONS
  Extubation in the operating room was successful in 87.1% of the patients without any increase in mortality and morbidity, but with a decrease in ICU length of stay and less use of hospital resources.
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India. Electronic address: gargrajnish11@gmail.com.
authors.forename: Rajnish
authors.initials: R
authors.lastname: Garg
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: Shekhar
authors.initials: S
authors.lastname: Rao
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: Colin
authors.initials: C
authors.lastname: John
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: Chinnaswamy
authors.initials: C
authors.lastname: Reddy
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Hegde
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: Keshava
authors.initials: K
authors.lastname: Murthy
authors.affiliation: Division of Pediatric Cardiac Sciences, Narayana Institute of Cardiac Sciences, Bangalore, India.
authors.forename: P V S
authors.initials: PV
authors.lastname: Prakash
mesh_terms: D000293:Adolescent; D000367:Age Factors; D060666:Airway Extubation / Q000379:methods* / Q000401:mortality; D000758:Anesthesia / Q000379:methods; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D009873:Operating Rooms; D010348:Patient Care Team; D010820:Physicians; D011446:Prospective Studies; D066231:Surgeons
keywords: congenital heart surgery; early extubation; pediatric anesthesia; safety