Fast-Track Extubation After Modified Fontan Procedure

Study Questions:

What are the feasibility, safety, and clinical outcomes of extubation of patients in the operating room (OR) after Fontan procedures?

Methods:

A retrospective review was performed at a single center. The timing of extubation was determined by the attending surgeon and anesthesiologist. Patients remained intubated for unstable hemodynamics, impaired respiratory effort, significant chest tube bleeding, hypothermia, upper airway edema, or impaired level of consciousness. Patients were divided into three groups based on timing of extubation.

Results:

A total of 97 patients were studied, including 46 patients (47%) extubated in the OR (group A), 19 patients (19.6%) extubated in the intensive care unit (ICU) within 24 hours (group B), and 32 patients (33%) with delayed extubation. The mean age at the time of Fontan procedure was 3.9 ± 2.2 years, with a mean weight of 15.1 ± 5.0 kg. Twenty-four hours postoperatively, group A had a lower mean central venous pressure compared with patients in group B or C (13 vs. 14 vs. 17 mm Hg, respectively, p < 0.001); lower fluid balance (234 vs. 514 vs. 730 ml, p < 0.001); and a lower inotropic score (4.6 vs. 6.7 vs. 10.8, p < 0.001). Group C had a longer median ICU length of stay (2 vs. 3 vs. 6 nights, p = 0.01), kept chest tubes longer (8 vs. 9 vs. 15 days, p = 0.001), and had a longer median hospital length of stay (9 vs. 11 vs. 21 days, p = 0.001).

Conclusions:

Extubation in the OR after a modified Fontan procedure is feasible and associated with improved early postoperative hemodynamics, earlier time to chest tube removal, and shorter ICU and hospital length of stays.

Perspective:

Given the deleterious effects of positive intrathoracic pressure on pulmonary blood flow and hemodynamics, patients with Fontan physiology may benefit from extubation as soon as possible after surgery. This study shows feasibility of an extubation in the OR for patients undergoing Fontan repair. The patient age at time of Fontan was somewhat older than some centers, with a mean age of 3.9. Importantly, it is difficult to make any assumptions of causality on improved outcomes with early extubation, as the sicker patients would have been selected to remain on the ventilator coming out of the OR. For example, while inotropic score was used as an outcome measure, hemodynamic instability was a criterion for staying on the ventilator in the early postoperative period. Additionally, it is unknown as to whether there is a benefit to an extubation in the OR strategy as compared with extubation after an initial stabilization period in the ICU (2-6 hours). The re-intubation rate was low in this study at 8.7%, with most re-intubations due to postoperative bleeding.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Outcome Assessment (Health Care), Lactoglobulins, Heart Defects, Congenital, Water-Electrolyte Balance, Fontan Procedure, Airway Extubation, Body Weight, Edema, Hemodynamics, Postoperative Hemorrhage, Intubation, Hypothermia, Central Venous Pressure, Coronary Artery Bypass, Hemorrhage


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