Extubation in the Operating Room after Fontan Operation

Objective: Negative intrathoracic pressure caused by spontaneous ventilation is an important driving force for blood flow in Fontan circulation. The avoidance of positive pressure ventilation in the postoperative management is therefore of potential benefit. The goal of this study was to assess the impact of immediate postoperative extubation in the operating room on hemodynamics and early outcome after Fontan operation (FO) in comparison to later extubation on the intensive care unit.

Methods: Between 2013 and 2016, a total of 114 children (mean age 3.8 ± 2.3 years; mean weight 15.2 ± 6.8 kg) with univentricular cardiac defects underwent FO with an extracardiac conduit: 60 patients were immediately extubated in the operating room (IE group) and 54 on the intensive care unit (ICUE group) after a median of 195 minute. (range: 30–515 minutes). The medical pre-, intra- and postoperative data (191 parameters) were retrospectively analyzed.

Results: The overall hospital survival was 100%. Only one patient from the IE group needed reintubation because of laryngospasm. The mean hospital stay was 17.5 ± 6.8 days and did not differ between groups. Patients in the IE group had lower heart rate, arterial and central venous blood pressure and showed less frequently metabolic acidosis 2–3 hour after arrival on the ICU. Furthermore, less inotropic support and volume supplementation were needed throughout the postoperative course. Patients from the IE group had also less pleural effusions within the first 48 hours ([Table 1]).

	IE (n = 60)	ICUE (n = 54)	p-Value
Heart rate [bpm]	106.5 ± 3.99	120.3 ± 5.96	<0.001
Blood pressure systolic/diastolic/central venous	90.6 ± 2.09/49.6 ± 1.38/10.4 ± 0.66	93.5 ± 6.43/53.6 ± 4.33/11.4 ± 1.42	0.024/<0.001/0.001
pH 2–3 h after FO	7.36 ± 0.04	7.30 ± 0.47	<0.001
Dopamine support [h]	9.75 ± 11.28	12.77 ± 11.68	0.033
Fluid requirement [mL/kg/24 h]	54.11 ± 31.19	73.76 ± 46.09	0.019
Effusions [mL/kg] 48 h after FO	37.9 ± 17.48	49.5 ± 26.10	<0.001

Conclusion: Immediate extubation in the operating theater after the FO is feasible, safe and can be routinely performed. This regimen seems to promote faster hemodynamic adaptation to the Fontan circulation with less therapeutic interventions and therefore is a recommendable modification of the management.