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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence S. Fox Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Heinle, J. S. Articles by Fox, L. S. Search for Related Content PubMed Articles by Heinle, J. S. Articles by Fox, L. S.

J Thorac Cardiovasc Surg 1998;116:536
© 1998 Mosby, Inc.

Letters To The Editor

Early extubation after cardiac operations in neonates and young infants

Reply to the Editor

We appreciate the interest of Joffe and colleagues in our manuscript and would like to address their comments.

We disagree with their statement that the driving force behind early extubation is financially motivated. The article describes many of the potentially deleterious effects of prolonged tracheal intubation, mechanical ventilation, and the interventions necessary to maintain them. We believe these complications could be reduced or eliminated by earlier extubation. Clearly, patient safety and morbidity reduction are the motivating forces behind the concept of early extubation. We do believe, however, that the rapid changes occurring as a result of managed and capitated care should make all of us look carefully at the financial implications of how we care for patients.

The article states that all 3 patients (11% of all those extubated early) requiring reintubation are neonates and that 2 of the 3 were operated on in the first week of life. This reintubation is not different from that in the ventilated group or for the previous year group. The article further states: "Patients who are operated on in the first week of life or who have single ventricle physiology may not always be appropriate candidates for early extubation, and care should be taken when evaluating these patients for extubation."

We also reference the work of Valley and Bailey. However, no patient in our study required reintubation because of decreased ventilatory effort. We believe that caudal opioids provide effective pain control and reduce the requirement for intraoperative and postoperative narcotics.

Joffe and colleagues suggest that the length of intensive care unit stay may be more a function of the severity of the patient's disease than a function of when the patient was extubated. We agree with this. However, comparison of average days in the intensive care unit for the early extubation group and the previous year group (when patients were not extubated early) shows a significant difference that is not accounted for by patient severity alone.

Joffe incorrectly summarizes the results of Dr. Anand's study when stating that "high-dose intraoperative opioids coupled with postoperative opioid analgesia and mechanical ventilation improved outcome in neonates undergoing cardiac operations." Anand and Hickey are careful to point out that "this clinical trial is too small to allow firm conclusions about the associations among anesthetic techniques, increased stress responses, and poor outcome in neonates."

We appreciate the comments of Joffe and colleagues and hope that this discussion stimulates further interest and investigation in this area.

Cook Children's Medical Center, Fort Worth, TX 76104

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence S. Fox Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Heinle, J. S. Articles by Fox, L. S. Search for Related Content PubMed Articles by Heinle, J. S. Articles by Fox, L. S.