Abstract
Objective To identify patients at high risk for failed early extubation in the operating room
(OR) following the Fontan procedure and generate a predictive model to allow improved
clinical decision making.
Design The success of an early-extubation strategy (extubation in the OR) was reviewed in
patients aged 0 to 17 years old, undergoing the Fontan procedure between 2008 and
2011. Patients who required reintubation following primary extubation in the OR were
compared with those who did not. Logistic regression with a backward variable selection
was used to develop a predictive model in two stages: first, using pre-/perioperative
predictors and then using postoperative predictors among the first-stage positive.
Setting Canadian quaternary-care university children's hospital PICU. The treatment policy
was changed from the routine extubation in PICU to extubation in the OR in January
2008.
Results A total of 75 patients met our inclusion criteria: 8 patients required reintubation.
Patients' average body weight was 14.5 kg (standard deviation [SD] 3.7), average age
was 3.5 (SD 1.9) years, and average preoperative transcutaneous arterial saturation
was 80.9% (SD 6.8). The first-stage predictive model contained three predictors: concomitant
procedure (odds ratio [OR] >999, 95% confidence interval [CI] 15.7-infinity, p < 0.001), total bypassing time (cutoff; ≥99 minutes) (OR >999, 95% CI 6.5-infinity,
p < 0.001), and absence of fenestration for pre/operative variables (OR >999, 95% CI
9.5-infinity, p < 0.001). The second-stage model included chest-tube fluid loss (CTFL ≥9.9 mL/kg/first
6 h). Our sequential prediction model had net sensitivity of 87.5% and specificity
of 77.6%.
Conclusion We produced a predictive model for failed early extubation in Fontan patients. The
sensitivity and specificity values are in the range of clinical utility. The model
should be validated with an independent sample with a larger sample size.
Keywords
anesthesia - pediatric - congenital heart disease - CHD
