Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium
Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium
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DOI：
10.1097/pcc.0000000000000498
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发表时间：
2015-11-01
影响因子：
4.1
通讯作者：
Cooper, David S.
中科院分区：
文献类型：
--
作者：
Gaies, Michael;Tabbutt, Sarah;Cooper, David S.
目的：描述儿科心脏 ICU 治疗的多中心患者队列中拔管失败的临床流行病学。设计：使用前瞻性收集的临床登记数据进行回顾性队列研究。设置：儿科心脏重症监护联盟登记处。患者：所有入住儿科心脏重症监护联盟医院 CICU 的患者。干预措施：无。测量和主要结果：对登记处自 10 月 1 日以来的所有机械通气事件进行分析。 2013年至2014年7月31日。拔管失败的主要结果是在计划拔管后不到48小时重新插管。使用广义估计方程进行重复测量分析来解释患者和中心内的相关性，以确定拔管失败的风险因素。使用控制患者因素的逻辑回归计算每家医院调整后的拔管失败率。在 1,734 例机械通气事件（8 家医院的 1,478 名患者）中以计划拔管结束，其中有 100 例拔管失败 (5.8%)。在多变量分析中，只有较长的机械通气持续时间与拔管失败显着相关（p = 0.01）；通风少于24小时时故障率为4%，24小时后故障率为9%，7天后故障率为13%。在心脏手术室插管和拔管的 503 名患者中，15 名患者（3%）在 48 小时内未能拔管（24 小时内有 12 名患者）。各医院的病例组合调整后拔管失败率从 1.1% 到 9.8% 不等。拔管失败的患者的中位心脏 ICU 住院时间（15 与 3 d；p < 0.001）和院内死亡率（7.9 vs 1.2%；p < 0.001）更长。结论：虽然拔管失败总体上并不常见，但对于通气超过 24 小时的患者，可能有机会改进拔管准备评估。这些数据表明，心脏手术后在手术室拔管的失败率较低。我们观察到各医院拔管失败率存在差异，未来的调查必须阐明高绩效中心的最佳策略，以减少通气时间，同时限制拔管失败。
Objective: To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs.Design: Retrospective cohort study using prospectively collected clinical registry data.Setting: Pediatric Cardiac Critical Care Consortium registry.Patients: All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals.Interventions: None.Measurements and Main Results: Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001).Conclusions: Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.