TRACHEAL EXTUBATION OF CHILDREN IN THE OPERATING-ROOM AFTER ATRIAL SEPTAL-DEFECT REPAIR AS PART OF A CLINICAL-PRACTICE GUIDELINE

Early tracheal extubation in the operating room after atrial septal de fect (ASD) surgery was recommended as part of a clinical practice guid eline (CPG) established in the Cardiovascular Program at the Children' s Hospital, Boston, MA. This retrospective review was undertaken to de termine whether this practice was efficient without compromising patie nt care. The charts and hospital charges for 102 patients undergoing s ecundum ASD or sinus venosus defect surgery between March 1992 and Jul y 1994 were reviewed; 36 patients (Group I) had surgery prior to intro duction of the CPG, and 66 patients were managed according to the CPG. Of the latter 25 patients (Group II) were tracheally extubated in the operating room (OR) and 41 patients (Group III) were extubated in the cardiac intensive care unit (CICU). Patients in all three groups were similar with respect to height, weight, and surgical conditions inclu ding cardiopulmonary bypass time, lowest esophageal temperature, hemat ocrit, total OR time, and the time from completion of bypass to leavin g the OR. Patients in Group II received significantly less fentanyl du ring anesthesia, were more likely to have a respiratory acidosis on ad mission to the CICU, and had an increased frequency of vomiting in the CICU. There was no difference in duration of CICU stay among groups. The length of hospital stay was reduced in Groups II and III after int roduction of the CPGs, but was not influenced by tracheal extubation i n the OR. There was no difference among groups in the hospital charges for OR, anesthesia, and CICU time. However, when the combined hospita l charges for services provided both in the OR and CICU were included, patients in Group II were charged significantly less, and this primar ily reflects the absence of postoperative mechanical ventilation charg es. Tracheal extubation in the OR after ASD surgery in children can re sult in lower patient charges without significantly compromising patie nt care.