J Thorac Cardiovasc Surg 1998;116:536
© 1998 Mosby, Inc.
Early extubation after cardiac operations in neonates and young infants
Denise Joffe, MD,
Peter J. Davis, MD,
Ira S. Landsman, MD,
Susan Firestone, MD
To the Editor
The article by Heinle, Diaz, and Fox
1 reports on their experience with early tracheal extubation of pediatric neonatal patients undergoing cardiac surgery. In view of the economic forces motivating such practice, it is not surprising that "fast-tracking" of patients having cardiac operations is also being evaluated in pediatrics. The authors of this study conclude: "Early extubation can be accomplished safely in many neonates and young infants undergoing cardiac surgery for repair of congenital heart defects and can shorten hospital stay and reduce costs." Although the authors present interesting data, we believe there are two issues that they need to further address.
1. Safety. It is unclear whether early tracheal extubation of 28 patients allows one to make any conclusions about safety. Of interest is that the authors note that only 11% of the extubated patients required reintubation. However, on further examination of the patients, all of the reintubated patients were neonates. These three patients constituted 25% of the neonatal population that underwent early tracheal extubation. We do not believe that a 25% reintubation rate for neonates can be dismissed as "safe practice."
In addition, the safety of spinal axis opioids in neonates requires further evaluation. Valley and Bailey 2 noted a higher incidence of respiratory depression in patients under 1 year of age who received supplemental intravenous opioids in addition to spinal axis morphine. Since all patients in the study reported by Heinle, Diaz, and Fox 1 received both intravenous and epidural opioids, respiratory depression observed in these patients may have been influenced by this combined mode of opioid delivery.
2. Since the driving force behind early tracheal extubation of ventilated patients appears to be financially motivated, the authors noted that their patients who underwent early tracheal extubation remained in the intensive care unit for an average of 3.3 days. Although this stay was shorter than that of the ventilated group, this suggests that length of stay in the intensive care unit may be more a function of the patient's disease and the philosophy of the institution's postoperative care than the moment the patient's trachea was extubated.
We think this study is important but needs to be placed in context with the published study of Anand and Hickey, 3 which demonstrated that high-dose intraoperative opioids coupled with postoperative opioid analgesia and mechanical ventilation improved outcome in neonates undergoing cardiac operations.
Department of AnesthesiologyChildren's Hospital of Pittsburgh,
Pittsburgh, PA 15213-2583
References
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Heinle JS, Diaz LK, Fox LS. Early extubation after cardiac operations in neonates and young infants. J Thorac Cardiovasc Surg 1997;114:413-8.[Abstract/Free Full Text]
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Valley RD, Bailey AG. Caudal morphine for postoperative analgesia in infants and children: a report of 138 cases. Anesth Analg 1991;72:120-4.[Free Full Text]
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Anand K, Hickey P. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992;361:1.
