Hemodynamic instability is not a contraindication for early extubation after Total cavopulmonary connection - a review of 337 patients

Introduction: Early extubation has been suggested after Total cavopulmonary connection (TCPC). We aimed to prove if extubation in the first few postoperative hours is feasible also in the unstable patients after TCPC.

Methods: We studied all patients who received primary TCPC in our center for 13,5 years. We compared the ventilation times, reintubation rates, volume requirements and maximal vasoactive-inotropic score (VIS) in the patients before 2008 and after 2009, as at that time our strategy moved towards aggressive early extubation in all patients after TCPC. The ventilation times and reintubation rates of the unstable patients (who exceeded the 75. percentiles for volume need - 145.9ml/kg or VIS - 20) after 2009 were compared with those of the other patients.

Results: The study included 337 patients. Compared to those before 2008 (n=199) the patients after 2009 (n=138) were ventilated shorter (34.3±53.1 vs. 6.1±5.9 hours, p<0.001), had similar reintubation rates (4.5% vs. 5.1%, p=0.82), needed less volume (161±234 vs. 115±115 ml/kg, p=0.047) and more inotropes (VIS - 12.3±12.6 vs. 15.1±10.2, p=0.03). The ventilation times of the unstable patients after 2009 (n=48) were comparable to these of the others (7.0±8.2 vs. 5.6±4.2 hours, p=0.18), however they needed more frequent reintubations (6/48 vs. 1/90, p=0.004), most often due to respiratory reasons. Four patients after 2009 needed ventilation more than 24 hours because of delayed sternal closure, surgical revision for bleeding, cooling after resuscitation and hemodynamic instability, which resolved after stenting of the left pulmonary artery.

Conclusions: Most patients after TCPC can be extubated in the first few hours after surgery regardless of their circulation status. This could be an additional tool to improve hemodynamics in the unstable patients early postoperatively.