The following is a summary of “Fast-track Extubation Guided by pulmonary artery pressure monitoring after ventricular septal defect closure in infants with pulmonary hypertension,” published in the February 2024 issue of Pediatrics by Araki et al.

In pediatric cardiac surgery, adopting a fast-track extubation approach has emerged as a promising strategy, curtailing hospital stays and yielding considerable reductions in medical costs. This study endeavors to meticulously assess the viability of the fast-track extubation method, particularly scrutinizing its application in infants with preoperative pulmonary hypertension (PH) undergoing ventricular septal defect (VSD) closure while concurrently investigating the utility of intraoperative pulmonary artery pressure (PAP) monitoring in this cohort.

A retrospective analysis including 102 infants afflicted with VSD and preoperative PH (mean PAP > 20 mmHg on cardiac catheterization) was conducted, with the exclusion of four cases involving complex procedures and prolonged cardiopulmonary bypass times for associated lesions. The assessment of the fast-track extubation approach hinged on intraoperative systolic PAP monitoring, with a threshold set at <35 mmHg. Operation room extubation following VSD closure delineated the essence of the fast-track extubation approach. The study also sought to identify predictors of postoperative adverse events, encompassing in-hospital mortality, PH crises, extended mechanical ventilation durations, and nitric oxide (NO) administration.

Implementation of the fast-track extubation approach was executed in 39 patients (38 %), yielding a meager 1 % in-hospital mortality in a non-fast-track patient attributable to postoperative PH crisis. A fractional percentage (5.1 %) of patients in the fast-track group necessitated re-intubation post-procedure due to upper airway complications. Notably, the fast-track group exhibited significantly diminished NO inhalation and pulmonary hypertensive medication administration compared to the non-fast-track group (P < 0.001). Multivariate analysis underscored the significance of body weight of <4 kg at surgery (P = 0.006), surgeries performed by trainees (P = 0.003), and elevated intraoperative systolic PAP (P < 0.001) as substantial risk factors for postoperative adverse events.

In summary, discerning findings advocate for the feasibility of the fast-track extubation approach post-VSD closure in infants with preoperative PH, evidenced by minimal occurrences of re-intubation and postoperative adverse events. The judicious inclusion of intraoperative systolic PAP measurements proves instrumental in identifying eligible candidates for the fast-track extubation approach, thereby contributing to enhanced perioperative management strategies.

Source: sciencedirect.com/science/article/abs/pii/S1058981324000080