(213) The Use of Post-Extubation Noninvasive Respiratory Support in Infants Following Stage 1 Palliation

Introduction: Following stage 1 surgical palliation (S1P), single ventricle (SV) neonates suffer extubation failure (EF) a reported 10-22% of the time. Prophylactic NRS decreases re-intubation rates in general CICU patients, however, prolonged NRS may contribute to unintended morbidity. CICU providers face a significant challenge in identifying which SV neonates will benefit from extubation to NRS without incurring the added morbidity from prolonged NRS. Factors associated with prolonged NRS are ill defined. The primary objective of this study is to identify associations with prolonged NRS in SV neonates undergoing S1P.

Methods: This is a retrospective cohort study of neonates with SV heart disease who underwent S1P with a BTT or Sano shunt at Boston Children’s and Sickkids Hospitals between 2019 and 2023. Demographic, operative, and post-operative variables were collected. The primary outcome was prolonged NRS (HFNC, CPAP, BiPAP) defined as ≥ 72 hours post-extubation. Secondary outcomes included reintubation within 48 hours and clinical outcomes such a nutritional status, sedative exposure, and length of stay. Logistic and stepwise multivariate regression modeling was used to evaluate predictors and prolonged NRS respectively.

Results: 127 neonates were included, 118 of which (92.9%) underwent Sano modification. 71 patients (55.9%) received NRS for ≥ 72 hours post-extubation. 27 patients (21.3%) were reintubated within 48 hours of extubation. Prolonged NRS patients had a higher rate of unplanned reoperation (50%vs. 29%; p=0.041) and longer postoperative mechanical ventilation (6.8 days vs. 5.1 days; p=0.014). Having a genetic syndrome (AOR 2.68, 95% CI 1.01-7.06; p=0.047) and longer duration of neuromuscular blockade (NMBA) (AOR 1.16, 95%CI 1.03-1.30; p=0.012) were independently associated with prolonged NRS. Patients receiving prolonged NRS had longer CICU LOS (22 days vs. 11 days; p< 0.001), sedative exposure (48 days vs. 16 days; p< 0.001), and exposure to parenteral nutrition (8 days vs. 2 days; p< 0.001). Prolonged NRS patients had evidence of worse malnutrition at CICU discharge.

Conclusions: The duration of post-operative NMBA use and presence of a genetic syndrome were associated with prolonged NRS. Prolonged NRS was associated with significantly worse clinical outcomes in neonates following S1P.