Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery.

OBJECTIVES: Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT. DESIGN: Retrospective cohort study. SETTING: CICU at a tertiary-care children's hospital. PATIENTS: Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01). CONCLUSIONS: Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.

Extracorporeal Membrane Oxygenation.

The utilization of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support continues to increase globally, with > 190,000 ECMO cases reported to the international Extracorporeal Life Support Organization Registry. The present review aims to synthesize important contributions to the literature surrounding the management of mechanical ventilation, prone positioning, anticoagulation, bleeding complications, and neurologic outcomes for infants, children, and adults undergoing ECMO in 2022. Additionally, issues related to cardiac ECMO, Harlequin syndrome, and anticoagulation during ECMO will be discussed.

Pressure attenuation during high-frequency airway clearance therapy across different size endotracheal tubes: An in vitro study.

PURPOSE: High-frequency airway clearance therapy is a positive pressure secretion clearance modality used in pediatric and adult applications. However, pressure attenuation across different size endotracheal tubes (ETT) has not been adequately described. This study quantifies attenuation in an in vitro model. MATERIALS AND METHODS: The MetaNeb® System was used to deliver high-frequency pressure pulses to 3.0, 4.0, 6.0 and 8.0mm ID ETTs connected to a test lung during mechanical ventilation. The experimental setup included a 3D-printed trachea model and imbedded pressure sensors. The pressure attenuation (Patt%) was calculated: Patt%=[(Pproximal-Pdistal)/Pproximal]x100. The effect of pulse frequency on Pdistal and Pproximal was quantified. RESULTS: Patt% was inversely and linearly related to ETT ID and (y=-7.924x+74.36; R(2)=0.9917, P=.0042 for 4.0Hz pulse frequency and y=-7.382+9.445, R(2)=0.9964, P=.0018 for 3.0Hz pulse frequency). Patt% across the 3.0, 4.0, 6.0 and 8.0mm I.D. ETTs was 48.88±10.25%, 40.87±5.22%, 27.97±5.29%, and 9.90±1.9% respectively. Selecting the 4.0Hz frequency mode demonstrated higher Pproximal and Pdistal compared to the 3.0Hz frequency mode (P=.0049 and P=.0065). Observed Pdistal was <30cmH2O for all experiments. CONCLUSIONS: In an in vitro model, pressure attenuation was linearly related to the inner diameter of the endotracheal tube; with decreasing attenuation as the ETT size increased.