title: Early postoperative extubation of unstable patients following total cavopulmonary connection: impact on circulation and outcome.
abstract: OBJECTIVE
  We aimed to investigate whether early postoperative extubation following the Fontan operation is universally feasible and can be used as a management tool in unstable patients.
  
  
  METHODS
  All patients undergoing the Fontan operation in our centre between 2004 and 2013 (n=253) were analysed. Until 2008, patients were extubated according to standard criteria and comprised group 1. Group 2 included all patients presenting after 2009, when early extubation was always aimed regardless of the haemodynamic status. Patients who exceeded the 75th percentiles for volume requirements and inotrope scores for the respective group were defined as unstable. Comparisons of outcomes between groups and subgroups and analysis of the changes in haemodynamic and treatment parameters with extubation in unstable patients after 2009 were performed.
  
  
  RESULTS
  Compared with group 1, patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.50), and needed less volume (p=0.01). In group 2, the unstable patients were not ventilated for longer durations (p=0.19), but had higher re-intubation rates (p=0.03) than the stable patients. Compared with the unstable patients from group 1, the unstable patients from group 2 were ventilated for shorter duration (p<0.001), had similar re-intubation rates (p=0.66), and needed less volume (p=0.006). There was a significant acute and sustained increase in mean arterial pressure with extubation and a parallel reduction in volume requirements and inotrope scores in the unstable patients from group 2.
  
  
  CONCLUSIONS
  Timely extubation is universally applicable following the Fontan operation. Early postoperative extubation can be valuable for improving Fontan haemodynamics.
authors.affiliation: 1Department for Pediatric Cardiology and Congenital Heart Disease,German Heart Center Munich,Technical University Munich,Munich,Germany.
authors.forename: Stanimir
authors.initials: S
authors.lastname: Georgiev
authors.affiliation: 1Department for Pediatric Cardiology and Congenital Heart Disease,German Heart Center Munich,Technical University Munich,Munich,Germany.
authors.forename: Gunter
authors.initials: G
authors.lastname: Balling
authors.affiliation: 1Department for Pediatric Cardiology and Congenital Heart Disease,German Heart Center Munich,Technical University Munich,Munich,Germany.
authors.forename: Bettina
authors.initials: B
authors.lastname: Ruf
authors.affiliation: 1Department for Pediatric Cardiology and Congenital Heart Disease,German Heart Center Munich,Technical University Munich,Munich,Germany.
authors.forename: Kilian
authors.initials: K
authors.lastname: Ackermann
authors.affiliation: 2Department for Cardiovascular Surgery,German Heart Center Munich,Technical University Munich,Germany.
authors.forename: Jelena P
authors.initials: JP
authors.lastname: von Ohain
authors.affiliation: 2Department for Cardiovascular Surgery,German Heart Center Munich,Technical University Munich,Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Schreiber
authors.affiliation: 1Department for Pediatric Cardiology and Congenital Heart Disease,German Heart Center Munich,Technical University Munich,Munich,Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Ewert
mesh_terms: D000328:Adult; D060666:Airway Extubation; D005260:Female; D018729:Fontan Procedure; D005858:Germany; D006330:Heart Defects, Congenital / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D007902:Length of Stay; D008297:Male; D011184:Postoperative Period; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Fontan operation; early extubation; intensive care