High Mortality Rate After Extubation Failure After Pediatric Cardiac Surgery A.D.J. Ten Harkel, 1 M.M.J. van der Vorst, 2 M.G. Hazekamp, 3 J. Ottenkamp 4 1 Department of Pediatric Cardiology, Erasmus MC-Sophia, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands 2 Department of Pediatrics, Faculty of Medicine, University of Kuwait, Kuwait City, Kuwait 3 Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands 4 Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands Abstract. The objective of this study was to evaluate the different causes of extubation failure and the consequent mortality rates in a pediatric population after cardiac surgery. We studied 184 consecutive patients with a median age of 9 months (range, 0–165). In 158 patients, extubation was successful (group A). Nine patients were reintubated for upper airway obstruction and finally extubated successfully (group B). Seventeen patients were reintubated for cardiorespiratory failure, finally leading to death in 11 of 17 patients (65%) (group C). Group B patients were younger and had a longer intubation period comparedtogroupApatients.GroupCpatientshad more reoperations (30% vs4% in group A patients, p <0.001),alowerPaO 2 on admission at the intensive care unit as well as just prior to extubation, a lower base deficit before extubation, and needed more inotropic support during their stay in the intensive care unit. We conclude that extubation failure after pediatric cardiac surgery due to cardiorespiratory failure is a bad prognostic sign. Patients with high inotropicsupportandalowPaO 2 priortoextubation are especially at risk and probably need careful evaluation before final extubation. Key words: Cardiac surgery — Pediatric — Reintu- bation — Cardiorespiratory failure — Upper airway obstruction Weaning from mechanical ventilation and timing of endotracheal extubation are crucial components in the management of patients after cardiac surgery. Prolonged mechanical ventilation causes numerous complications, such as atelectasis, infection, tissue damage, postintubation stridor, and tube blockage [16]. Therefore, it is crucial to identify the time to start the weaning process and to identify the patients who are likely to fail the trial of weaning [16]. The usefulnessofseveralparameterstopredictextubation success and failure in infants and children has been investigated [6, 20]. Ventilatory parameters such as a low spontaneous tidal volume, a high FiO 2 ,orahigh peak ventilatory inspiratory pressure [20], as well as other factors such as the presence of a congenital syndrome, preoperative pulmonary hypertension, and intraoperative circulatory arrest [6], have been described as risk factors for failed extubation. The outcomes after reintubation after cardiac surgery in an adult population provide conflicting results, with increased [3, 10, 15] or similar [14] mortality after reintubation. However, the outcome after extubation failure in a pediatric population after cardiac surgery has not been elucidated. We analyzed mortality rates among patient groups with different causes of extu- bation failure. We hypothesized that risk factors al- ready present before extubation may at least partially predict the eventual reintubation rate. Patients and Methods We retrospectively reviewed medical records of 190 patients (age, <16 years) who were admitted after cardiac surgery in the pedi- atric intensive care unit (PICU) of the Leiden University Medical Center(LUMC)fromJanuary1996toMay1997.Sixpatientsdied before extubation could be attempted and were excluded from further analysis. Before leaving the operating room, transesopha- gealechocardiographywasperformedroutinelytoexcluderesidual defects. If significant, these residual defects were corrected. The weaning process was started when the patients were he- modynamicallystableandwereassessedbytheattendingphysician to be capable of sustaining spontaneous breathing. From the start oftheweaningprocess,patientswereventilatedinthesynchronized intermittent mandatory ventilation mode with a maximum FiO 2 of 0.4. During the weaning process, the assisted mechanical breath Correspondence to: A.D.J. Ten Harkel, email: A.Tenharkel@ erasmusmc.nl Pediatr Cardiol 26:756–761, 2005 DOI: 10.1007/s00246-005-0906-7