Pediatric Cardiac Anesthesiology Fellow Childrens Healthcare of Atlanta Decatur, Georgia, United States
Abstract:
Introduction: Institutions variably utilize oral (OI) versus nasal intubation (NI) for neonatal cardiac surgery. The perceived advantages of NI include lower rate of intraoperative endotracheal tube dislodgement, decreased sedation requirements, and improved oral feeding ability but carries additional risk of nasal mucosa breakdown and sinusitis, is technically more difficult, and more time consuming [1-4]. During the study period there were also quality initiatives related to standardized sedation protocols, improved endotracheal tube securement, and protocolized post-operative feeding in this patient population.
Methods: This single-center, retrospective study evaluated the association of the route of intubation with unplanned extubation, hospital length of stay, postoperative length of stay, otolaryngology (ENT) consult, feeding site, and sedation medications. Neonates undergoing cardiopulmonary bypass surgery from 2017-2020 were included. Patients who were intubated pre-operatively were excluded. Chi-square and Fisher’s exact test were used to compare categorical data while a Wilcoxon exact test was used to compare groups.
Results: Out of the 244 total patients, 63% (n = 154) were OI and 36% (n = 90) were NI. Graph 1 demonstrates change in practice of the intubating site by each year with no nasal intubations in 2017 and 30 nasal intubations in 2020. Table 1 lists demographic data with comparable weight, median age, and percentage of syndromic patients between the two groups. There was no difference in unplanned extubation, length of hospital stay, length of intubation, or feeding type at time of transfer from the intensive care unit or discharge from the hospital as listed in Table 2. The OI group had a decrease in anesthesia induction duration by approximately 6 minutes. There was a significant increase in nasal mucosa breakdown in the NI group (9% in nasal vs 1% in oral) and percentage receiving an alpha agonist. Interestingly, there was a decrease in ENT consult in the NI group; however, this was not statistically significant (p value = 0.059). Sedation administration between the groups was similar. For benzodiazepines, the nasal group received less lorazepam and midazolam however this was not statistically significant (midazolam p value = 0.08) while dexmedetomidine use increased significantly over the study period.
Conclusions: NI for neonatal cardiac surgery may result in increased risk of postoperative nasal mucosa breakdown. There is a potential benefit of decreased benzodiazepine use which is confounded in this study by increased dexmedetomidine use. This study does not observe improved oral feeding in the NI versus the OI group which differs from other published studies, suggesting other factors in quality improvement around feeding are more influential than NI.
