Duration of Mechanical Ventilation and Perioperative Care Quality After Neonatal Cardiac Operations

摘要

Background This study was conducted to determine whether the duration of mechanical ventilation (DOMV) could be used to benchmark the overall quality of care after neonatal congenital heart operations.;Methods Children aged younger than 30 days undergoing cardiac operations were reviewed. Technical adequacy was assessed using the Technical Performance Score (TPS), a previously validated tool for determining the adequacy of a palliative or corrective surgical procedure that uses echocardiography criteria and need for unplanned reintervention to determine technical adequacy. Preoperative risk factors and postoperative complications were determined using The Society of Thoracic Surgeons Congenital Heart Surgery Database definitions. Surgical complexity was assessed using The Society of Thoracic Surgeons–European Association of Cardio-Thoracic Surgery (STAT) Mortality Categories. We explored associations between preoperative risk factors, STAT category, TPS, and postoperative complications with DOMV.;Results Of 601 patients studied, 49 were not included in the multivariable analysis due to a STAT nonclassifiable operation or unmeasured TPS, or both. Multiple risk factors were associated with longer DOMV, including weight (p?= 0.005), The Society of Thoracic Surgeons Congenital Heart Surgery Database preoperative factors (p?= 0.005), STAT mortality category (p < 0.001), TPS (p < 0.001), and The Society of Thoracic Surgeons Congenital Heart Surgery Database–defined complications (p < 0.001). Multivariable regression showed that preoperative factors increased DOMV by 1.23 days (p?= 0.01), class 3 TPS by 2.16 days (p < 0.001), and postoperative complications by 2.03 days (p < 0.001), with adjusted R2?= 0.42.;Conclusions Neonates with major residual lesions and postoperative complications have prolonged DOMV. DOMV may reflect the quality of care after congenital heart operations.;;The Supplemental TablesSupplemental Tables can be viewed in the online?version of this article [http://dx.doi.org/10.1016/j.athoracsur.2016.11.077] on http://www.annalsthoracicsurgery.org.;After the Boston Children’s Hospital Institutional Review Board approved this study, we retrospectively reviewed hospital medical records, the respiratory care database, and data reported to The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). All patients aged younger than 30 days who underwent cardiac operations between January 1, 2009, and January 31, 2013, were included. Patients were excluded if the sole operation was cannulation for extracorporeal membrane oxygenation, patent ductus arteriosus ligation, or pacemaker implantation. The multivariable analysis excluded 49 patients who underwent complex operations that could not be classified by STS–European Association of Cardio-Thoracic Surgery (STAT) Mortality Categories [14][14] or had undefined TPS, or both.Abstracted data included clinical and demographic data, operative details, preoperative risk factors, and postoperative complications according to STS-CHSD definitions (Table?1Table?1 and Table?2Table?2, respectively) [15, 16]. Of the STS-CHSD preoperative risk factors, we excluded “other preoperative factors” due to lack of specificity. Postoperative complications were considered to have equal weight for the analysis. Nonmodifiable factors that may affect DOMV included age, gender, weight and height, STAT mortality category, and STS-CHSD preoperative risk factors. Potentially modifiable factors included cardiopulmonary bypass time, aortic cross-clamp time, TPS, and STS-CHSD postoperative complications. For postoperative complications, we excluded “pulmonary hypertension” and “pulmonary hypertensive crisis” due to unclear definition, “prolonged mechanical ventilation” and “reintubation” due to collinearity with our outcome measurement, and “other” due to lack of specificity. For simplicity, because determining retrospectively which complications were avoidable is impossible, we assumed tha