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Predicting delayed extubation and transfer to the intensive care unit in children undergoing posterior fusion surgery for scoliosis

A retrospective observational study

Vorhersage einer verzögerten Extubation und Verlegung auf die Intensivstation bei Kindern, die sich einer Skolioseoperation mit posteriorer Fusion unterziehen

Eine retrospektive Beobachtungsstudie

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Abstract

Background

Delayed extubation and transfer to the intensive care unit (ICU) in children undergoing major scoliosis surgery may increase postoperative complications, prolong hospital stay, and increase medical expenses; however, whether a child will require delayed extubation or transfer to the ICU after scoliosis orthopedic surgery is not fully understood. In this study, we reviewed the risk factors for delayed extubation and transfer to the ICU after scoliosis orthopedic surgery in children.

Method

The electronic medical records of pediatric patients (≤ 18 years) who underwent posterior spinal fusion surgery between January 2018 and November 2021 were reviewed and analyzed. Patient characteristics (age, sex, body mass index, American Society of Anesthesiologists, ASA, grade, preoperative lung function, and congenital heart disease), preoperative Cobb angle, scoliosis type, correction rate, vertebral fusion segments, pedicle screws, surgical osteotomy, intraoperative bleeding, intraoperative allogeneic transfusion, intraoperative hemoglobin changes, intraoperative mean arterial pressure changes, intraoperative tidal volume (ml/kg predicted body weight), surgical time, postoperative extubation, and transfer to the ICU were collected. The primary outcomes were delayed extubation and transfer to the ICU. Multivariate logistic regression models were used to determine the risk factors for delayed extubation and ICU transfer.

Results

A total of 246 children who satisfied the inclusion criteria were enrolled in this study, of whom 23 (9.3%) had delayed extubation and 81 (32.9%) were transferred to the ICU after surgery. High ASA grade (odds ratio [OR] 5.42; 95% confidence interval [CI] 1.49–19.78; p = 0.010), high Cobb angle (OR 1.04; 95% CI 1.02–1.07; p < 0.001), moderate to severe pulmonary dysfunction (OR 10.9; 95% CI 2.00–59.08; p = 0.006) and prolonged surgical time (OR 1.01; 95% CI 1.00–1.03; p = 0.040) were risk factors for delayed extubation. A high Cobb angle (OR 1.02; 95% CI 1.01–1.04; p = 0.004), high intraoperative bleeding volume (OR 1.06; 95% CI 1.03–1.10; p = 0.001), allogeneic transfusion (OR 3.30; 95% CI 1.24–8.83; p = 0.017) and neuromuscular scoliosis (OR 5.38; 95% CI 1.59–18.25; p = 0.007) were risk factors for transfer to the ICU. A high Cobb angle was a risk factor for both delayed extubation and ICU transfer. Age, sex, body mass index, number of vertebral fusion segments, correction rate, and intraoperative tidal volume were not associated with delayed postoperative extubation and ICU transfer.

Conclusion

The most common risk factor for delayed extubation and ICU transfer in pediatric patients who underwent posterior spinal fusion was a high Cobb angle. Determining risk factors for a poor prognosis may help optimize perioperative respiratory management strategies and planning of postoperative care for children undergoing complicated spinal surgery.

Zusammenfassung

Hintergrund

Verzögerte Extubation und Verlegung auf die Intensivstation (ICU) bei Kindern, die sich einer größeren Skolioseoperation unterziehen, können postoperative Komplikationen erhöhen, den Krankenhausaufenthalt verlängern und die medizinischen Kosten steigern. Es ist jedoch nicht vollständig verstanden, ob ein Kind nach einer orthopädischen Skolioseoperation eine verzögerte Extubation oder Verlegung auf die ICU benötigen wird. In dieser Studie haben wir die Risikofaktoren für verzögerte Extubation und Verlegung auf die ICU nach orthopädischer Skolioseoperation bei Kindern überprüft.

Verfahren

Die elektronischen Krankenakten pädiatrischer Patienten (≤ 18 Jahre), die sich zwischen Januar 2018 und November 2021 einer Spondylodese der hinteren Wirbelsäule unterzogen, wurden überprüft und analysiert. Die Patientenmerkmale (Alter, Geschlecht, Body-Mass-Index, ASA-Klassifikation der ASA [Amerikanischen Gesellschaft für Anästhesiologie], präoperative Lungenfunktion und angeborene Herzkrankheiten), präoperativer Cobb-Winkel, Skoliosetyp, Korrekturrate, fusionierte Wirbelsegmente, Pedikelschrauben, chirurgische Osteotomie, intraoperative Blutung, intraoperative allogene Transfusion, intraoperative Hämoglobinveränderungen, intraoperative mittlere arterielle Druckänderungen, intraoperatives Tidalvolumen (ml/kg prognostiziertes Körpergewicht), Operationsdauer, postoperative Extubation und Verlegung auf die Intensivstation wurden erfasst. Die primären Endpunkte waren verzögerte Extubation und Verlegung auf die Intensivstation. Multivariate logistische Regressionsmodelle wurden verwendet, um die Risikofaktoren für verzögerte Extubation und die Verlegung auf die Intensivstation zu ermitteln.

Ergebnisse

Insgesamt wurden 246 Kinder, die die Einschlusskriterien erfüllten, in diese Studie eingeschlossen, von denen 23 (9,3 %) eine verzögerte Extubation hatten und 81 (32,9 %) nach der Operation auf die Intensivstation verlegt wurden. Ein hoher ASA-Grad (Odds-Ratio [OR] 5,42; 95 % Konfidenzintervall [KI] 1,49–19,78; p = 0,010), ein hoher Cobb-Winkel (OR 1,04; 95 % KI 1,02–1,07; p < 0,001), eine moderate bis schwere Lungenfunktionsstörung (OR 10,9; 95 % KI 2,00–59,08; p = 0,006) und eine verlängerte Operationsdauer (OR 1,01; 95 % KI 1,00–1,03; p = 0,040) waren Risikofaktoren für verzögerte Extubation. Ein hoher Cobb-Winkel (OR 1,02; 95 % KI 1,01–1,04; p = 0,004), ein hohes intraoperatives Blutungsvolumen (OR 1,06; 95 % KI 1,03–1,10; p = 0,001), allogene Transfusion (OR 3,30; 95 % KI 1,24–8,83; p = 0,017) und neuromuskuläre Skoliose (OR 5,38; 95 % KI 1,59–18,25; p = 0,007) waren Risikofaktoren für die Verlegung auf die Intensivstation. Ein hoher Cobb-Winkel war ein Risikofaktor sowohl für die verzögerte Extubation als auch für die Verlegung auf die Intensivstation. Alter, Geschlecht, Body-Mass-Index, Anzahl der fusionierten Wirbelsegmente, Korrekturrate und intraoperatives Tidalvolumen standen nicht im Zusammenhang mit der verzögerten postoperativen Extubation und der Verlegung auf die Intensivstation.

Fazit

Der häufigste Risikofaktor für eine verzögerte Extubation und die Verlegung auf die Intensivstation bei pädiatrischen Patienten, die sich einer Spondylodese der hinteren Wirbelsäule unterzogen haben, war ein hoher Cobb-Winkel. Die Identifizierung von Risikofaktoren für eine ungünstige Prognose kann dazu beitragen, die perioperative Atemwegsmanagementstrategie zu optimieren und die Planung der postoperativen Versorgung von Kindern mit komplexen Wirbelsäuleneingriffen zu verbessern.

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All data generated or analyzed during this study are included in this published article.

Abbreviations

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

FVC:

Forced vital capacity

ICU:

Intensive care unit

MAP:

Mean arterial pressure

PBW:

Predicted body weight

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Acknowledgements

We thank our colleagues in pediatric orthopedics for their kind assistance to provide the patients imaging data. In particular, we are very grateful to our patients and their guardians for their consent to use their imaging data.

Funding

The work was supported by Shanghai Municipal Health Commission Clinical Research Project (No. 202240109). The funder has no role in study design, data collection, analysis and manuscript preparation.

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Authors and Affiliations

  1. Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200092, Shanghai, China

    Lai Wang,  Qin Xia,  Di Zhuang,  Xianya Tong,  Lai Jiang Ph.D &  Yanfei Mao Ph.D

  2. Department of Anesthesiology, Eye & ENT Hospital, Fudan University, 200031, Shanghai, China

    Wenwen Ni

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  1. Lai Wang
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Contributions

YM and LJ conducted the trial conception and design the trial. LW, QX, DZ and XT collected the data. LW, QX and WN analyzed the data. LW and QX wrote the draft. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Lai Jiang Ph.D or Yanfei Mao Ph.D.

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Conflict of interest

L. Wang, Q. Xia, W. Ni, D. Zhuang, X. Tong, L. Jiang and Y. Mao declare that they have no competing interests.

Ethical standards.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case. This retrospective observational study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines and was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Medical Ethics Committee of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (XHEC-C-2022-007‑1, date of approval: 11 January 2022) and the requirement for written informed consent was waived due to the retrospective nature of the study. All methods were performed in accordance with relevant guidelines and regulations.

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Erweiterte deutsche Zusammenfassung

Diese Arbeit wurde für Die Anaesthesiologie in Englisch eingereicht und angenommen. Die erweiterte deutsche Zusammenfassung finden Sie am Ende des gedruckten Artikels.

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Wang, L., Xia, Q., Ni, W. et al. Predicting delayed extubation and transfer to the intensive care unit in children undergoing posterior fusion surgery for scoliosis. Anaesthesiologie (2024). https://doi.org/10.1007/s00101-024-01391-8

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  • DOI: https://doi.org/10.1007/s00101-024-01391-8

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