Coarctation of the aorta: to extubate early or to extubate late

Introduction Coarctation of the aorta is a common congenital abnormality that requires surgical repair in most instances with a challenging anesthetic management. Fast tracking has been introduced to cardiac anesthesia in order to limit post operative ventilator complications, to conserve expensive resources and to allow a shorter hospital course. Immediate extubation is an integral part of fast tracking which is a composite term involving multidisciplinary management. Aim and objective We compared the post operative course of 2 groups of children who had surgical repair of coarctation of the aorta through lateral thoracotomy; one group was immediately extubated in the OR; on table extubation (OTE) at the end of surgery and the other was left intubated and transferred ventilated to the ICU. We compared the adequacy of BP control (estimated from the average hourly rate of nitroglycerin infusion), the need for reintubation, the incidence of occurrence of surgical bleeding and the post operative ICU stay. Material and methods A total of 60 patients (2 months 6 years) were randomly assigned into one of the two groups: one group (group E) were extubated at the end of the procedure and the other group (group I) were left intubated and transferred ventilated to the ICU. The patients in both groups were closely monitored for BP rise postoperatively (as related to the 50 percentile of the BP tables obtained from “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, NIH, 2005), the rate of nitroglycerin infusion as a vasodilator was also recorded, the need for reintubation was reported in both groups together with the occurrence of bleeding that necessitates surgical control and also the length of ICU stay was reported. Results Immediate extubation; on table extubation (OTE) of children who have had surgical repair for coarctation of Pediatric Anesthesia and Critical Care Journal 2016;4(1):35-42 doi:10.14587/paccj.2016.8 Mohammed et al. Fast tracking in coarctation of the aorta 36 the aorta was associated with a higher post operative blood pressure that required higher hourly doses of vasodilators. Also it was noticed that trying to control BP using supplemental opioid analgesia partly caused respiratory depression that required reintubation. The rise of BP that followed immediate extubation might be the cause for post operative bleeding that required surgical exploration. In addition, immediate extubation didn’t result in a significantly reduced post-operative ICU stay. Conclusion The practice of immediate extubation; on table extubation (OTE) in the OR for children who underwent surgical repair of aortic coarctation via thoracotomy did not decrease post operative ICU stay and it was associated with the need for a higher doses of vasodilators and increased incidence of bleeding and reintubation.