Predictive Analysis Of Tracheal Re-intubation And Acute Kidney Injury After Neonatal Cardiac Surgery

BackgroundThe anatomical and physiological development of neonates is immature,which is usually combined with severe respiratory insufficiency.The failure of tracheal extubation after cardiac surgery is easy to lead to many adverse consequences.At the same time,30%45%of neonates will suffer from acute kidney injury(AKI)after cardiac surgery,which will significantly increase the risk of perioperative complications and death.Therefore,this study aims to analyze and predict the prognosis of neonates from the aspects of tracheal extubationfailure(EF)and AKI after cardiac surgery.Objective1、To explore risk factors of EF in low birth weight(LBW)neonates undergoing congenital heart surgery;2、To compare the acute kidney injury(AKI)incidence and outcomes according to the pediatric Risk,Injury,Failure and Loss,and End-Stage(pRIFLE),AKI Network(AKIN),Kidney Disease Improving Global Outcomes(KDIGO),and modified KDIGO(mKDIGO)criteria in neonates following congenital cardiac surgery;3、To establish a predictive model based on clinical characteristics so as to recognize the risk of neonatal cardiac surgery associated-AKI(CSA-AKI).MethodsA clinical database of all neonates undergoing congenital cardiac surgery admitted to Guangdong provincial People’s hospital from January 2010 to September 2021 was retrospectively analyzed.Risk factors of EF were analysed by univariate and multivariate logistic regression analysis;AKI was based on the pRIFLE,AKIN,KDIGO and mKDIGO classification.The predictive abilities for postoperative outcomes were compared by receiver operating curves.After multivariate logistic regression,identified independent predictive factors associated with AKI were incorporated into the nomogram and ROC curve.Additionally,internal validation was performed and multivariate logistic regression analysis was used to assess the association of AKI definitions with postoperative outcomes.Results1、99 infants met the inclusion criteria,the multivariate logistic regression analysis identified preoperative mechanical ventilation and prolonged mechanical ventilation prior to first attempted extubation as risk factors for EF.2、522 neonates met the inclusion criteria,.After multivariate analysis,all definitions were found to be significant predictors of increased mortality.The AUCs for mortality were substantially different with pRIFLE(AUC,0.795),AKIN(AUC,0.724),KDIGO(AUC,0.819)and mKDIGO(AUC,0.831)(P<0.01)across the entire population,whereas the mKDIGO system was more accurate than the pRIFLE,AKIN and KDIGO systems.3、In the study population of 609 patients,less intraoperative urine output,more intraoperative RBC use,more intraoperative DHCA time,higher VIS score and elevated serum lactate when transferred to ICU were predictive factors of CSA-AKI using multivariate analysis.Internal validation showed good discrimination of the model with area under the curve(AUC)of 0.804.Further multivariable logistic regression showed that AKI was significant predictor of increased in-hospital mortality(odds ratio,12.61;95%confidence interval,3.00～37.48;P<0.001).Conclusions1、The prevalence of EF was very high in LBW infants undergoing congenital cardiac surgery.Preoperative mechanical ventilation and prolonged mechanical ventilation prior to first attempted extubation were independent risk factors for EF.2、The mKDIGO system was more accurate in predicting in-hospital mortality than the pRIFLE,AKIN and KDIGO systems in neonates after heart surgery.3、The novel predictive nomogram achieved a good perioperative prediction of CSA-AKI.Through the model,the risk of an individual patient with postoperative AKI undergoing cardiac surgery could be obtained during surgery or when transferred to ICU and such application was helpful for timely intervention in order to improve patient’s prognosis.