Evolution of practices: Early extubation in high-risk infants after pediatric cardiac surgery

Background In pediatric cardiac surgery, early extubation has been proved to be a safe and beneficial practice in most situations. However, it is not known if it is feasible in high-risk infants, notably neonates and infants undergoing complex surgical procedures. The aim of the study was to compare the prevalence of early extubation in a population of high-risk infants at two different eras and the factors associated with the duration of mechanical ventilation. Methods We compared two historical matched cohorts of 27 neonates and infants under 1 year of age. One cohort included patients of the year 2014 and the other patients of 2018 and 2019. The main endpoint was early extubation defined as extubation in the first 24 hours (H24) after surgery. We also analyzed hemodynamic variables, inotropic drugs use and presence or absence of delayed sternal closure. Results The duration of mechanical ventilation was significantly shorter in the more recent cohort (median of 40 h versus 69 h in the former cohort), data using the Kaplan–Meier method are presented in Fig. 1, with a log-rank test not significant. The rate of extubation before H24 after surgery, though more elevated, was not significantly different. This was associated with the use of a different inodilator (milrinone in the first era and enoximone in the second era) and a less frequent use of vasopressors. We also observed less delayed sternal closures in the second period (only 2 patients whereas there were 10 patients in the first period). In a subgroup analysis comparing infants without delayed sternal closure, the observed trends were still present but there was no significant difference on the main endpoint and the duration of mechanical ventilation. Conclusion Early extubation after pediatric cardiac surgery in high-risk infants tends to be more prevalent in recent times. Facilitating factors and best practices are not yet precisely defined especially concerning the hemodynamic management of patients.