Pediatric Cardiology

, Volume 37, Issue 6, pp 1127–1136 | Cite as

Impact and Challenges of a Policy Change to Early Track Extubation in the Operating Room for Fontan

  • Atsushi KawaguchiEmail author
  • Qi Liu
  • Sean Coquet
  • Yutaka Yasui
  • Dominic Cave
Original Article


While policy changes toward early extubation in the operating room (OR) have been commonly seen in palliative surgeries in single ventricle anatomy, no systematic assessment of their impact on patient outcome has been reported. All patients aged 0–17 years admitted to a PICU in a quaternary children’s hospital for post-operative management following a primary Fontan procedure between 2005 and 2011 were included. Patients for revision of Fontan or patients admitted to adult Cardiovascular Intensive Care Unit were excluded. Practice policy was changed from routine extubation in the PICU to early extubation in OR in January 2008. Data were compared between the pre-policy-change era (2005–2007) and the post-policy-change era (2008–2011) to assess the impact of the change on patient outcomes. Generalized linear regression (GLM) and interrupted time series (ITS) analysis were used to access the effect of policy change on PICU length of stay and post-operative fluid balance, adjusting for potential confounders using propensity scores. Root cause analysis (RCA) was conducted to describe causes of failed extubation and challenges of this policy change. One hundred twenty-seven children met inclusion criteria. Average body weight was 14.7 kg [standard deviation (SD) 3.9], and age was 3.5 years (SD 1.9). A clear change in extubation practice occurred between the pre- versus post-policy-change eras: 97.5 % were extubated in the PICU in the pre-policy-change era, as compared to 15.0 % in the post-policy-change era. The average PICU length of stay was shortened by 4.1 days from the pre-policy-change era to the post-policy-change era [95 % CI −1.2 to −6.9, p < 0.01] in the GLM, whereas the ITS analysis did not show a statistically significant difference [95 % CI 1.8 to −2.5] (p = 0.23). No statistically significant difference was observed in the fluid balance in the 24 h post-operation in both analyses. Sixteen patients (16/127, 12.6 %) were reintubated mainly for hemodynamic instability in the pre-policy-change era (6/39, 15.4 %) and excessive bleeding or respiratory etiologies in the post-policy-change era (10/88, 11.4 %). Significant reduction of PICU length of stay was achieved without any evidence of worsening of patient outcomes. RCA suggests watchful observations with respect to bleeding and respiratory etiologies are the key to prevent failure of extubation in the current practice.


Extubation Fontan Operating room PICU Qualitative analysis Root cause analysis 



Operating room


Pediatric Intensive Care Unit


Generalized linear regression


Interrupted time series


Standard deviation


Positive-pressure ventilation


Cardiovascular Intensive Care Unit


Root cause analysis


Inter-quartile range


Partial thrombin time


Prothrombin time-international normalized ratio


Risk adjustment for surgery for congenital heart disease


Authors’ Contributions

Atsushi Kawaguchi Dr. Kawaguchi conceptualized, designed the study and data collection protocols, collected all data, carried out initial analysis, conducted root cause analysis, and drafted the initial manuscript, revised the initial manuscript, and approved the final manuscript as submitted. Dominic Cave Dr. Cave conceptualized the study, revised the data collection protocol, supervised the data collection, reviewed and revised the initial manuscript, and approved the final manuscript as submitted. Sean Coquet Dr. Coquet conducted root cause analysis, reviewed and revised the initial manuscript, and approved the final manuscript as submitted. Qi Liu Ms. Liu supervised data analysis and carried out, and approved the final data analysis and manuscript as submitted. Yutaka Yasui Dr. Yasui supervised data analysis and approved the final data analysis, reviewed and revised the initial manuscript and approved final manuscript as submitted.

Compliance with Ethical Standards

Conflict of interests


Supplementary material

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Supplementary material 1 (DOCX 24 kb)
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Supplementary material 2 (DOCX 433 kb)
246_2016_1406_MOESM3_ESM.docx (28 kb)
Supplementary material 3 (DOCX 28 kb)
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Supplementary material 4 (DOCX 28 kb)


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Atsushi Kawaguchi
    • 1
    • 2
    Email author
  • Qi Liu
    • 2
  • Sean Coquet
    • 3
  • Yutaka Yasui
    • 2
  • Dominic Cave
    • 1
    • 4
  1. 1.Department of Pediatrics, Pediatric Critical Care Medicine, Stollery Children’s HospitalUniversity of AlbertaEdmontonCanada
  2. 2.School of Public HealthUniversity of AlbertaEdmontonCanada
  3. 3.Department of Anesthesiology, Perioperative Medicine and Pain ManagementUniversity of SaskatchewanSaskatoonCanada
  4. 4.Department of Anesthesiology and Pain MedicineUniversity of AlbertaEdmontonCanada

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