European Journal of Cardiovascular Medicine

Fast-track recovery protocols in cardiac surgery are gaining worldwide popularity and have contributed to a significant reduction in the postoperative hospital stay and cost without any increase in postoperative morbidity and mortality. Early extubation is one of the major components of the fast-track recovery protocols^[1].

Conventional management after open heart surgery includes a period of effective ventilation coupled with sedation and paralyzing agents, a prolonged period of recovery, and delayed return of the patient to normal activity.

Improvement in cardiopulmonary bypass techniques, specifically advances in membrane oxygenation and blood-sparing techniques, has reduced the cerebral, pulmonary, renal, and bleeding complications of cardiac surgery. Recent technological advances in diagnostic cardiology, anesthesia, surgery, and perioperative management strategies contributed to successful early extubation. This avoids potentially deleterious effects of mechanical ventilation as laryngotracheal trauma, barotraumas, pneumothorax, and mucus plugging in the ETT, ventilation-associated pneumonia, etc.^[2-4]. In order to eliminate these effects of prolonged intubation and to reduce the hospital stay and iatrogenic complications, we studied the concept of early extubation in patients undergoing surgery for congenital heart disease on-pump.

Aim of study - The purpose of the present study was to determine the feasibility of early extubation in patients who underwent intracardiac repair for congenital heart disease. The patients were observed for the time to extubate after surgery.

This is a prospective study of 37 consecutive patients undergoing intracardiac repair for congenital heart disease between June 2023 to January 2025 in Government Medical College and Hospital, Chh. Sambhajinagar. Patients were divided into two subgroups- early extubation (< 4 hours) and delayed extubation (> 4 hours), and pulmonary hypertension was grouped as mild/moderate/severe depending on mean pulmonary artery pressure where mild - < 20 mmHg; moderate- 20-40 mmHg; severe- > 40 mmHg. Cases with reduced pulmonary blood flow were excluded from this study.

The essential aspects of early extubation included choice of anesthetic agents, hemodynamic stability, and good postoperative analgesia.

Surgery was achieved through a midline sternotomy, cardiopulmonary bypass, aortic cross clamp, moderate hypothermia to 29-34 degrees Celsius, and cold blood cardioplegic arrest. ASDs were closed with an autologous untreated pericardial patch, VSD was closed with PTFE patch. Continuous ultrafiltration was done for the patients weighing < 10 kg and who had severe PAH. Patients were weaned from cardiopulmonary bypass with support of NTG, adrenaline, and for patients with severe PAH, milrinone was used with adrenaline.

For extubation, criteria such as stable hemodynamics, warm peripheries, core temperature between 36- 37 degrees Celsius, adequate muscle power (neck holding), urine output, adequate arterial blood gases, acceptable hematocrit, chest tube drainage, and pain control were considered. Where early extubation was < 4 hours and delayed extubation > 4 hours.

Postoperative pain was managed with IV. fentanyl, NSAIDs, tramadol, and diclofenac suppository.

Single team carried out all operations. Patients were observed for the time required for extubation early (within 4 hours) and late (after 4 hours) extubation with respect to patient’s age, sex, weight, diagnosis, severity of PAH, duration of CPB (cardiopulmonary bypass), ACC (aortic cross clamp) and mean duration of ventilation. Results were studied using statistical analysis using chi-square test.

Out of the 37 patients who underwent open heart surgery for congenital heart disease, 21 (62.16%) were male and 16 (37.84%) were female patients. The age group was between 3 months to 5 years, with a mean age of 2.1 years. Weight between 2.2 to 19 kg, with a mean weight of 8.4 kg. 27 (72.97%) patients were of severe PAH. The mean cardiopulmonary bypass time was 56.78 minutes. The mean cross-clamp time was 30.28 minutes. The duration of extubation time was 50 min to 785 min, and the mean extubation time was 121 minutes. Out of 27 cases of severe PAH, 23 were extubated within four hours. Out of 9 cases of ASD with VSD with PAH, all were extubated within four hours. Out of 8 cases of VSD with PDA, 7 were extubated within 4 hours.  The only case of SAM was extubated within 4 hours. Out of the 37 patients, 32 (86.49 %) were extubated within four hours, 5 (13.51 %) were extubated between 4-12 hours. 3 patients developed pneumonia from the delayed extubation group, which was treated with injectable antibiotics and chest physiotherapy.

Table 1: Age/Sex Distribution.

Table 2: Diagnosis and extubation time distribution.

Table 3: Extubation time and PAH severity distribution

Prolonged mechanical ventilation was an essential part of postoperative care in cardiac surgery during its developing years. Recent advances in surgical and anesthetic techniques have facilitated early extubation following pediatric cardiac surgery. Potential benefits of an early extubation are decreased cardiac and respiratory morbidity, increased cardiac performance, and a lower rate of nosocomial pneumonia ^[5-9]. As a fundamental component of the fast-track protocols, early extubation has been shown to expedite intensive care unit discharge as well as overall length of stay, thus resulting in early recovery and decreased cost of patient care^[10].

Multiple studies from the Western world have shown the safety and efficacy of fast-track cardiac surgery. It has been conclusively demonstrated that this approach does not compromise the quality of care. Rather, it leads to early ambulation, increases patient satisfaction, and places less burden on the hospital and health care providers.

Early extubation of children after cardiac surgery has been suggested as a safe alternative to prolonged postoperative ventilation, but it is still not a common practice. Variables that have been shown in some studies to affect ventilation duration include younger age, severe pulmonary artery hypertension, and longer cardiopulmonary bypass & aortic cross-clamp duration, postoperative bleeding, congestive heart failure, and high inotropic requirement^[11]. The variables were not contributory to delayed extubation in our study. Early extubation was successfully achieved in the majority of patients, supporting the hypothesis that there should be no arbitrary time limits for postoperative extubation.

 In our Institution, patients are extubated when they meet standard criteria: awake, warm peripheries, no significant chest tube drain, hemodynamically stable, adequate oxygenation and ventilation. Adequate patient physiologic reserve, together with optimized postoperative intensive care unit care, should be the factors that determine the proper timing of early extubation.

Cardiopulmonary bypass duration has been associated with a higher incidence of prolonged ventilation ^[12,13]. Possible mechanisms for such association are reduced lung compliance, decreased functional residual capacity, increased alveolar-arterial oxygen pressure gradient, and atelectasis ^[14]. In agreement with other reports from the literature, the shortened cardiopulmonary bypass and aortic cross-clamp times were noted among patients extubated in fewer than 4 hours. It appears that although very few demographic parameters can distinguish patients capable of undergoing extubation in fewer than 4 hours, intraoperative factors such as cardiopulmonary bypass and aortic cross-clamp time may play important roles in allowing patients to be extubated earlier in the intensive care.

Pulmonary hypertension often complicates the perioperative care of many children with congenital heart disease. Chronically excessive pulmonary blood flow contributes to progressive dysfunction of the mechanisms of pulmonary vasorelaxation^[15]. Changes in the pulmonary vascular endothelial surface and increased production, release or activation of serine elastase in the vessel wall may contribute to the development of pulmonary vascular obstructive changes. In addition, endothelin, a potent vasoconstrictor peptide released from endothelial cells, is elevated in children with pulmonary hypertension secondary to congestive heart disease^[16,17]. Pulmonary artery hypertension does not seem to be a contraindicating factor to early extubation in patients who underwent intracardiac repair for congenital heart disease^[18]. In our series, the severity of pulmonary artery hypertension did not affect the duration of ventilation. This is signified by using the chi-square test in our study.

This study shows that the severity of pulmonary artery hypertension, type of congenital heart defect, age, and weight do not seem to be contraindicating factors to early extubation. Early extubation is highly challenging and involves an interplay of several complex factors. This process requires continuous evaluation, critical reappraisal, and emphasis on a multidisciplinary approach with particular attention to the availability and expertise of nursing staff and medical/paramedical personnel involved in patient care. The most important factor for early extubation may be to approach all of these patients as if they have the potential to be extubated early and then optimize the perioperative events to achieve this goal. When treated in this manner, neonates, infants, and young children undergoing cardiac operations for repair of congenital heart defects can be successfully extubated early in the postoperative period.

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