(841) Extubation Failure and Timing to Tracheostomy in Children Surviving Acute Neurological Injury

Introduction: Critically ill patients with acute neurological injury commonly require intubation. Current recommendations for assessing extubation readiness in children primarily focus on respiratory criteria and overlook neurological considerations. The true incidence and risk of extubation failure in pediatric patients with acute neurologic injury is not well reported; hence, the assessment for extubation readiness or the need for tracheostomy is challenging. This study aims to investigate the incidence of extubation failure, and factors associated with the need for tracheostomy in pediatric patients surviving an acute neurologic injury.

Methods: We conducted a retrospective cohort study using the Virtual Pediatric System (VPS) database of patients younger than 18 years of age with a neurological injury requiring intubation from 2012 to 2022. Patients that did not survive and those with congenital or spinal cord etiologies were excluded. Demographic and clinical variables were compared between subjects that were successfully extubated, those with early tracheostomy placement (14 days).

Results: Of the 38,810 enrolled subjects, 37,661 (97.04%) were successfully extubated, 481 (1.24%) underwent early tracheostomy, and 668 (1.72%) underwent late tracheostomy. Most patients were aged 29 days to < 2 years (30.75%). The most common etiologies were seizures (60.6%), trauma (20.9%), and neurovascular (16.48%). The successfully extubated subjects had a higher median initial GCS score (8 vs. 5 and 4, p< 0.001) and fewer median extubation attempts (1 vs 3 and 3, p< 0.001) than the tracheostomy cohorts. There was a significant difference in median ICU days between the three groups (2.51 vs. 18.3 vs. 38.3, p< 0.001).

Conclusions: The majority of pediatric patients requiring intubation following an acute neurological injury can be successfully extubated. Among patients requiring a tracheostomy, those who received it early had significantly shorter ICU and hospital stays. This study suggests that GCS scores may aid clinicians in determining if a patient is likely to successfully extubate or need tracheostomy, which may lead to earlier tracheostomy times and shorter ICU LOS. Large prospective studies are needed to better evaluate risk factors for extubation failure in pediatric patients with an acute neurological injury.