A retrospective cohort study of pediatric patients undergoing staged laparotomy with interstage extubation.

There is substantial evidence that prolonged mechanical ventilation after surgery leads to longer intensive care unit (ICU) and hospital length of stay (LOS). However, there is a paucity of data regarding interstage extubation in pediatric patients undergoing staged procedures.

Congenital portosystemic shunts (CPSS) are a condition in which venous splanchnic blood bypasses the liver and drains directly into the systemic circulation. At our institution, a two‐stage procedure is performed for cases which are not amenable to embolization in the interventional radiology suite. The venous malformation is partially occluded, and the patient is then transferred to the ICU with a temporary abdominal closure. Over approximately 5 days, the portal system is given time to expand to accommodate the extra blood flow. If the portal pressure is deemed to be acceptable on venogram, the patient returns to the operating room for permanent ligation.

The ideal perioperative care of these patients has not been well established. Early extubation of pediatric patients undergoing liver transplantation experienced shorter ICU admission, hospital LOS, and decreased opioid use. Historically, at the authors' institution, patients undergoing ligation of a CPSS remained intubated between their two stages. As our familiarity with the procedure has increased, so has our comfort level of extubating patients between stages (Appendix 1). We conducted a retrospective cohort study of all patients who underwent a two‐stage laparotomy for CPSS from 2016 to 2020. Patients who were extubated between stages were compared with patients who were not extubated between stages. Our goal was to compare the two groups and determine if there were any differences in ICU and total hospital LOS, duration of scheduled opioid and benzodiazepine administration, and scheduled methadone on discharge. Scheduled opioid and benzodiazepine were calculated as the number of days from the initiation of scheduled or continuous infusion until the day of the last scheduled dose. Comparisons were analyzed using logistic regression with calculation of odds ratios, confidence intervals, and p‐values.

Thirteen patients with CPSS were identified. Six of these patients were extubated between the first and second stages. Patients in the interstage extubation group were older than those who did not undergo interstage extubation (16 years vs. 2.8 years, Table 1). There were no differences in preoperative laboratory test results, preoperative shunt occlusion pressures, and American Society of Anesthesiologists physical status classification between the two groups.

TABLE 1

Univariable analysis of patients undergoing portosystemic ligation

Baseline characteristic	Median, IQR/n (%)			OR (95% CI)	p‐Value
	All patients, n = 13 (100%)	Interstage extubation, n = 6 (46.2%)	Not extubated, n = 7 (53.8%)
Gender, n (%)
Male	4 (30.8)	1 (16.7)	3 (42.9)		.559
Female	9 (69.2)	5 (83.3)	4 (57.1)
Age at surgery, years	5, 2.8–16	16, 4–16	2.8, 1.3–12		.031
Preoperative lab
Hemoglobin	12.6, 11.7–13.8	12.9, 11.7–13.8	12.6, 11.2–14.1		.943
Platelet	220, 200–270	248, 206–303	210, 194–223		.153
INR	1.1, 1.0–1.3	1.1, 1.0–1.1	1.2, 1.0–1.3		.234
Preoperative pressures
Nonoccluded shunt pressure	9, 6–11	9, 6–9	10, 6–11		.573
Occluded shunt pressure	24, 16–29	24, 19–27	23.5, 16–29		.745
ASA physical status classification, n (%)
2	3 (23.1)	2 (33.3)	1 (14.3)		.559
3	10 (76.9)	4 (66.7)	6 (85.7)
Weight	16.0, 12.2–71.6	59.8, 16.0–71.6	12.2, 10.9–75.8		.116
BMI	18.0, 15.1–22.2	20.0, 14.9–23.5	16.6, 15.1–22.2		.668
History of pulmonary disease	3 (23.1)	0	3 (42.9)		.192
Total days scheduled opioid	14, 7–27	6.5, 6–9	27, 15–33	0.67 (0–0.91)	.002
Total days scheduled benzodiazepine	9, 0–14	0, 0–8	14, 9–26	0.60 (0.08–0.95)	.008
Adjuvants
Ketamine	4 (30.8)	2 (33.3)	2 (28.6)	1.25 (0.12–13.24)	.853
Clonidine	4 (30.8)	1 (16.7)	3 (42.9)	0.27 (0.019–3.65)	.322
Dexmedetomidine	9 (69.2)	3 (50.0)	6 (85.7)	0.17 (0.01–2.36)	.186
Discharged on methadone	5 (38.4)	0	5 (71.4)	0.82 (0–0.83)	.03
Total length of mechanical ventilation, days	8, 1–11	1, 0–2	11, 9–17	0.64 (0–0.88)	.002
Cardiac arrest	1 (7.7)	0	1 (14.3)	1.17 (0–45.5)	.355
Total ICU stay, days	10, 8–20	8, 6–9	20, 13–20	0.52 (0–0.88)	.002
Total hospital stay, days	19, 14–28	13.5, 11–14	28, 19–33	0.59 (0.20–0.93)	.005

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; ICU, intensive care unit; INR, international normalized ratio; IQR, interquartile range; OR, odds ratio.

Operative length, blood loss, and post‐occlusion mesenteric pressures were not significantly different between the two groups. Patients who did not undergo interstage extubation were more likely to require pressors after their temporary ligation (71.4% vs. 16.7%). Postoperatively, both groups averaged 5 days in the ICU between the first and second stages. During the second stage of the operation, patients who were extubated between stages received more crystalloid compared with those who were not extubated between stages. No other significant variables were found between the two groups during the second stage of the operation. The median duration of mechanical ventilation was 1 day in the interstage extubation group vs. 11 days in the non‐extubated group.

Patients who were in the interstage extubation group had shorter ICU LOS and hospital LOS compared with the non‐interstage extubation group (8 days vs. 20 days). Patients who were extubated between stages received fewer days of scheduled opioids (6.5 days vs. 27 days) and fewer days of scheduled benzodiazepines (0 days vs. 14 days). More patients in the non‐interstage extubated group required methadone at discharge (0 patients vs. 5 patients).

Our study should only be interpreted within the context of the limitations inherent to a retrospective cohort study design. For example, there was not a fixed anesthetic or ICU protocol to guide the care. Each anesthesiologist decided which sedative drugs were administered, and these choices may have affected whether patients were extubated in an expedient manner (Appendix 2). Due to the retrospective nature of the study, we cannot determine causality between mechanical ventilation and increased ICU or hospital LOS. Future studies with a prospective design are needed to determine significant differences regarding safety and benefit. While this study consisted solely of patients undergoing CPSS ligations, our findings could have greater implications for all pediatric patients kept intubated in the ICU because of staged operations or multiple anesthetics due to the need for medical imaging or interventional radiology procedures over a short period of time.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

AUTHOR CONTRIBUTIONS

Mitchell L. Phillips helped in the design of the study, data acquisition, data analysis and interpretation, and drafting of the manuscript. Heather A. Ballard and Eric C. Cheon helped in the design of the study, data acquisition, data analysis and interpretation, and critical revision of the manuscript. Nick Volpe helped in the design of the study, data acquisition, and critical revision of the manuscript. Caroline P. Lemoine and Riccardo A. Superina helped in critical revision of the manuscript.

DATA AVAILABILITYSTATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Congenital cardiovascular disease

Moderate to severe pulmonary hypertension

Age <1 (relative contraindication)

Significant blood loss (>25 ml/kg)

Vasopressor requirement

Dexmedetomidine

Ketamine

Midazolam

Hydromorphone

Fentanyl

Morphine