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Higher Cumulative Dose of Opioids and Other Sedatives are Associated with Extubation Failure in Norwood Patients

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Abstract

Background

The primary purpose of this study is to evaluate the relationship between sedation usage and extubation failure, and to control for the effects of hemodynamic, oximetric indices, clinical characteristics, ventilatory settings pre- and post-extubation, and echocardiographic (echo) findings in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure.

Methods

Single-center, retrospective analysis of Norwood patients during their first extubation post-surgery from January 2015 to July 2021. Extubation failure was defined as reintubation within 48 h of extubation. Demographics, clinical characteristics, ventilatory settings, echo findings (right ventricular function, tricuspid regurgitation), and cumulative dose of sedation medications before extubation were compared between patients with successful or failed extubation.

Results

The analysis included 130 patients who underwent the Norwood procedure with 121 (93%) successful and 9 (7%) failed extubations. Univariate analyses showed that vocal cord anomaly (p = 0.05), lower end-tidal CO2 (p < 0.01), lower pulse-to-respiratory quotient (p = 0.02), and ketamine administration (p = 0.04) were associated with extubation failure. The use of opioids, benzodiazepines, dexmedetomidine, and ketamine are mutually correlated in this cohort. On multivariable analysis, the vocal cord anomaly (OR = 7.31, 95% CI 1.25–42.78, p = 0.027), pre-extubation end-tidal CO2 (OR = 0.80, 95% CI 0.65–0.97, p = 0.025), and higher cumulative dose of opioids (OR = 10.16, 95% CI 1.25–82.43, p = 0.030) were independently associated with extubation failure while also controlling for post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC), intubation length, and echo results.

Conclusion

Higher cumulative opioid doses were associated with a greater incidence of extubation failure in infants post-Norwood procedure. Therefore, patients with higher cumulative doses of opioids should be more closely evaluated for extubation readiness in this population. Low end-tidal CO2 and low pulse-to-respiratory quotient were also associated with failed extubation. Consideration of the pulse-to-respiratory quotient in the extubation readiness assessment can be beneficial in the Norwood population.

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Authors and Affiliations

  1. Department of Pediatrics, Division of Cardiology, Texas Children’s Hospital and Baylor College of Medicine, 1102 Bates Ave. Suite 430.01, Houston, Texas, 77030, USA

    Sebastian Acosta

  2. Baylor College of Medicine, Houston, Texas, USA

    Adel M. Hassan, Zbigniew Gugala & Zena Karagoli

  3. Department of Pharmacy, Texas Children’s Hospital, Houston, Texas, USA

    Jessica Hochstetler

  4. Department of Pharmacy, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA

    Amy L. Kiskaddon

  5. Department of Pediatrics, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA

    Amy L. Kiskaddon

  6. Department of Pediatrics, Division of Critical Care Medicine, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA

    Paul Checchia & Fabio Savorgnan

  7. Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA

    David Faraoni

  8. Department of Pediatrics, Division of Neonatology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA

    Feng Zheng

Authors
  1. Sebastian Acosta
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  2. Adel M. Hassan
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  9. Feng Zheng
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  10. Fabio Savorgnan
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The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Correspondence to Sebastian Acosta.

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Acosta, S., Hassan, A.M., Gugala, Z. et al. Higher Cumulative Dose of Opioids and Other Sedatives are Associated with Extubation Failure in Norwood Patients. Pediatr Cardiol 45, 8–13 (2024). https://doi.org/10.1007/s00246-023-03318-3

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