Con: Extubation in the operating room following pediatric cardiac surgery.

i m EXTUBATION IN THE OPERATING ROOM after surgery for correction of congenital heart defects in children, even in selected cohorts, has no proven benefit to patients or families, is associated with disguised resource consumption, and has never been demonstrated conclusively to shorten the duration of intensive care unit (ICU) or hospital stay. Furthermore, although extubation in the ICU after a short (2to 6-hour) period of stabilization is appropriate in selected patients, the routine application of early extubation after pediatric cardiac surgery cannot be justified. A systematic review and meta-analysis of the literature addressing early extubation, defined as extubation in the operating room or 6 hours after pediatric cardiac surgery, has been performed.1 Nine studies were deemed eligible for meta-analsis, with only 1 randomized, controlled trial identified. All 9 tudies were determined to be of poor methodologic quality. our studies that examined an early extubation cohort without n appropriate comparison group were identified. It was conluded that, although the practice of early extubation appears to e safe, sufficient evidence does exist to permit endorsement of his strategy on a routine basis.1 To date, there is only 1 randomized controlled trial comparing extubation in the operating room with delayed extubation. This trial enrolled 100 consecutive pediatric cardiac surgical patients (age range 1 month to 15 years) for extubation in the operating room or elective prolonged mechanical ventilation (approximately 25 hours).2 The study demonstrated no differnce between the groups in reintubation rate, mortality, septic r cardiac complications, abnormal radiographic findings, or he need for chest re-exploration. However, the study was owered inadequately to address these issues. Furthermore, the roup with extubation in the operating room was significantly lder and weighed more than the mandatory ventilation group. he investigators concluded that extubation in the operating oom was associated with shorter ICU and hospital stays. owever, because these time differences almost exactly atched the period of mandatory mechanical ventilation, this nding is expected and precludes establishing any meaningful ink between extubation in the operating room and shorter ength of stay in the ICU or the hospital. A key component of the success of extubation in the operting room is determining the patient population to which his strategy can be applied safely. Given the anatomic and hysiologic heterogeneity of the congenital heart disease opulation, it is no wonder that multiple factors, including ounger age, lower weight, prolonged cardiopulmonary byass time, use of circulatory arrest, pulmonary hypertension, risomy 21, and higher inotrope scores, have been associated ith prolonged ventilation after cardiac surgery.3-5 The difficulty of identifying risk factors reliably is illustrated by the lack of consensus on whether pulmonary hypertension represents a contraindication to extubation in the operating room.6 Pulmonary hypertension, defined simply as a mean hreshold pulmonary artery pressure, does not provide any eaningful insight into the suitability for extubation without nformation about pulmonary vascular resistance and pulonary vascular reactivity.7