Department of Pediatrics, Division of Cardiology, Texas Children's Hospital and Baylor College of Medicine, 1102 Bates Ave. Suite 430.01, Houston, Texas, 77030, USA.
Baylor College of Medicine, Houston, Texas, USA.
Pediatr Cardiol. 2024 Jan;45(1):8-13. doi: 10.1007/s00246-023-03318-3. Epub 2023 Oct 25.
The primary purpose of this study is to evaluate the relationship between sedation usage and extubation failure, and to control for the effects of hemodynamic, oximetric indices, clinical characteristics, ventilatory settings pre- and post-extubation, and echocardiographic (echo) findings in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure.
Single-center, retrospective analysis of Norwood patients during their first extubation post-surgery from January 2015 to July 2021. Extubation failure was defined as reintubation within 48 h of extubation. Demographics, clinical characteristics, ventilatory settings, echo findings (right ventricular function, tricuspid regurgitation), and cumulative dose of sedation medications before extubation were compared between patients with successful or failed extubation.
The analysis included 130 patients who underwent the Norwood procedure with 121 (93%) successful and 9 (7%) failed extubations. Univariate analyses showed that vocal cord anomaly (p = 0.05), lower end-tidal CO2 (p < 0.01), lower pulse-to-respiratory quotient (p = 0.02), and ketamine administration (p = 0.04) were associated with extubation failure. The use of opioids, benzodiazepines, dexmedetomidine, and ketamine are mutually correlated in this cohort. On multivariable analysis, the vocal cord anomaly (OR = 7.31, 95% CI 1.25-42.78, p = 0.027), pre-extubation end-tidal CO2 (OR = 0.80, 95% CI 0.65-0.97, p = 0.025), and higher cumulative dose of opioids (OR = 10.16, 95% CI 1.25-82.43, p = 0.030) were independently associated with extubation failure while also controlling for post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC), intubation length, and echo results.
Higher cumulative opioid doses were associated with a greater incidence of extubation failure in infants post-Norwood procedure. Therefore, patients with higher cumulative doses of opioids should be more closely evaluated for extubation readiness in this population. Low end-tidal CO2 and low pulse-to-respiratory quotient were also associated with failed extubation. Consideration of the pulse-to-respiratory quotient in the extubation readiness assessment can be beneficial in the Norwood population.
本研究的主要目的是评估在接受 Norwood 手术后的左心发育不全综合征（HLHS）新生儿中，镇静药物使用与拔管失败之间的关系，并控制血流动力学、血氧指数、临床特征、拔管前后的通气设置以及心脏超声（echo）检查的影响。
对 2015 年 1 月至 2021 年 7 月间接受首次手术后拔管的 HLHS 患儿进行单中心回顾性分析。将拔管后 48 小时内重新插管定义为拔管失败。比较成功拔管和失败拔管患者的人口统计学、临床特征、通气设置、拔管前心脏超声（右心功能、三尖瓣反流）结果和镇静药物累积剂量。
该分析共纳入 130 例接受 Norwood 手术的患儿，其中 121 例（93%）拔管成功，9 例（7%）拔管失败。单因素分析显示，声带异常（p=0.05）、呼气末二氧化碳（p<0.01）、呼吸比（p=0.02）和氯胺酮（p=0.04）与拔管失败有关。在本队列中，阿片类药物、苯二氮䓬类药物、右美托咪定和氯胺酮的使用相互关联。多变量分析显示，声带异常（OR=7.31，95%CI 1.25-42.78，p=0.027）、拔管前呼气末二氧化碳（OR=0.80，95%CI 0.65-0.97，p=0.025）和阿片类药物累积剂量较高（OR=10.16，95%CI 1.25-82.43，p=0.030）与拔管失败独立相关，同时也控制了拔管后呼吸支持（CPAP/BiPAP/HFNC 与 NC）、插管长度和超声结果。
在接受 Norwood 手术后的婴儿中，较高的阿片类药物累积剂量与更高的拔管失败发生率相关。因此，在该人群中，应更密切地评估累积阿片类药物剂量较高的患者是否具备拔管条件。呼气末二氧化碳和呼吸比低也与拔管失败相关。在评估拔管准备情况时考虑呼吸比可能对 Norwood 人群有益。
