Invited Commentary

Abstract

Dr d'Udekem discloses a financial relationship with Actelion and MSD.As surgeons, we often see the timing of extubation as the result of a battle between intensivists and surgeons, the surgeons pushing for earlier extubation and the intensivists looking for safety and prolonging unnecessarily, in our opinion, the length of ventilation. With this perspective, we tend to look at early failure of extubation as a phenomenon depending on an arbitrary decision. The current work from Shizuoka Children’s Hospital [1Miura S. Hamamoto N. Osaki M. Nakano S. Miyakoshi C. Extubation failure in neonates after cardiac surgery: prevalence, etiology, and risk factors.Ann Thorac Surg. 2017; 103: 1293-1299Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] makes us understand that extubation failure in neonates is more surely related to intrinsic patient characteristics than to external arbitrary factors. In this very well-conducted study of all the neonates operated on over the course of 6 years, causes of early extubation failure were prospectively collected. The current rate of extubation failure of 16% in neonates fits within the range reported in the current literature [2Laudato N. Gupta P. Walters III, H.L. Delius R.E. Mastropietro C.W. Risk Factors for extubation failure following neonatal cardiac surgery.Pediatr Crit Care Med. 2015; 16: 859-867Crossref PubMed Scopus (30) Google Scholar, 3Thiagarajan R.R. Bratton S.L. Martin L.D. Brogan T.V. Taylor D. Predictors of successful extubation in children.Am J Respir Crit Care Med. 1999; 160: 1562-1566Crossref PubMed Scopus (79) Google Scholar]. The authors claim that the severity of the disease was not a predictive factor for extubation failure. One could nonetheless remain suspicious that sicker patients will more often experience failure of a first attempt at extubation, because prolonged ventilation, younger age at operation, and delayed sternal closure were predictive of early extubation failure. Dr d'Udekem discloses a financial relationship with Actelion and MSD. There are several striking findings in this study. Half of the patients in whom extubation failed ended up requiring reoperation. The predominant reasons for early failure of extubation were respiratory causes. Even though only a quarter of these patients needed an intervention to solve their respiratory issues, the identification of the exact cause for failure of extubation seems to have helped in their subsequent management. There is no doubt that extubation failure is linked to higher mortality, prolonged hospital stays, higher burden of complications, and last but not least, higher hospital costs [4Gaies M. Tabbutt S. Schwartz S.M. et al.Clinical epidemiology of extubation failure in the pediatric cardiac ICU: A report from the Pediatric Cardiac Critical Care Consortium.Pediatr Crit Care Med. 2015; 16: 837-845Crossref PubMed Scopus (80) Google Scholar, 5Gupta P. Rettiganti M. Gossett J.M. et al.Risk factors for mechanical ventilation and reintubation after pediatric heart surgery.J Thorac Cardiovasc Surg. 2016; 151: 451-453Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. After reading this article by Miura and coworkers [1Miura S. Hamamoto N. Osaki M. Nakano S. Miyakoshi C. Extubation failure in neonates after cardiac surgery: prevalence, etiology, and risk factors.Ann Thorac Surg. 2017; 103: 1293-1299Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar], I will no longer attribute early extubation failure to mishandling of patients by my colleague intensivists. I will push for speedy investigation for causes of extubation failure because I now know that half of these patients may require an intervention that may remediate the situation and that the remaining will likely benefit in their management from the identification of this cause. I am now convinced that prompt extensive investigation of these patients will shorten their hospital stays. Extubation Failure in Neonates After Cardiac Surgery: Prevalence, Etiology, and Risk FactorsThe Annals of Thoracic SurgeryVol. 103Issue 4PreviewThe purpose of this study was to explore the prevalence, etiology, and risk factors of extubation failure (EF) in post–cardiac surgery neonates. Full-Text PDF