Accepted Manuscript Predictors of early outcome of arterial switch operation in patients with D-TGA Ahmed Mekkawy, Ahmed Ghoneim, MD, Osama El-Haddad, Joachim Photiadis, Ahmed Elminshawy, MD PII:
S1110-578X(17)30027-5
DOI:
10.1016/j.jescts.2017.03.003
Reference:
JESCTS 65
To appear in:
Journal of the Egyptian Society of Cardio-Thoracic Surgery
Received Date: 4 February 2017 Revised Date:
7 March 2017
Accepted Date: 7 March 2017
Please cite this article as: Mekkawy A, Ghoneim A, El-Haddad O, Photiadis J, Elminshawy A, Predictors of early outcome of arterial switch operation in patients with D-TGA, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), doi: 10.1016/j.jescts.2017.03.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
The new or re corrected statements are highlighted in yellow Predictors of early Outcome of Arterial Switch Operation in patients with
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D-TGA Authors: Ahmed Mekkawy1 Ahmed Ghoneim , MD 1
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Osama El-Haddad2
Ahmed Elminshawy, MD 1 Authors’ affiliations:
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Joachim Photiadis 2
1 Department of Cardiothoracic Surgery, Assiut University, Egypt 2 Cardiac surgery department, Berlin Heart Center at Charité Campus Virchow-
Corresponding Author:
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Klinikum Berlin , Germany
Ahmed Mohamed Abdel Hakim Mekkawy
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Assiut University Hospital, Department of Cardiothoracic Surgery, Assiut, Egypt Postal code:71526, E-mail:
[email protected].
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Funding sources: None
Conflicts of interest: None
Short running title:
Predictors of early Outcome of Arterial Switch Operation Words count: 4315
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ABSTRACT Background: The arterial switch operation has become the procedure of choice for the
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transposition of great arteries (TGA) and double outlet right ventricle DORV Taussig – Bing anomaly. The improvement in diagnosis, surgical techniques, and peri-operative management resulted in improvement in mortality and morbidity.
Objective: To evaluate the preoperative demographic, morphological and operative
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variables that affect the early outcome of the arterial switch procedure.
Patients and Methods: This is a retrospective study of 85 patients underwent arterial
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switch operation (ASO) in children’s cardiovascular program (Deutsches Herzzentrum, Berlin) between august 2012 and October 2015. It included all patients underwent ASO for D- transposition of great arteries (D-TGA) or double outlet right ventricle (DORV). Preoperative, operative and postoperative variable were studied and analyzed for their correlation to unfavorable early postoperative outcome [mortality or high morbidity such as need for extra-corporeal membrane oxygenation (ECMO), occurrence of coronary
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events and reoperation or catheter intervention].
Results: There were 3 (3,5%) early deaths in our study; 2 due to coronary ischemic events and one due to low cardiac output. Five coronary events and 17 early reoperations or catheter interventions were recorded. Several risk factors were associated
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with unfavorable outcome as low birth weight patients (P-value=0.03), preoperative corticosteroid intake (P-value=0,046), intramural course of coronary arteries (P-
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value=0.04), but retropulmonary course and mono-coronary ostium had no correlation to unfavorable outcome. There was no correlation between having simultaneous operative procedure and the unfavorable outcome (P-value=0.9). The predictors of unfavourable outcome included prolonged ischemic time (P-value=0.000), prolonged cardiopulmonary bypass time, prolongation of the ventilation time and increasing amount of postoperative bleeding (P-value =0,000). The increase in the ischemic time had a strong statistical correlation with the increased inotropic support in the postoperative period (Pvalue=0.002).
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Conclusions: The arterial switch operation can be performed without excess mortality. Simultaneous aortic arch repair can be done with no extra mortality. Prematurity, low birth weight, Taussig-Bing anomaly, intramural coronary artery course
risk factors for unfavourable outcome.
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KEYWORDS: predictors; arterial switch ; TGA ; outcome
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and some other coronary abnormalities, aortic cross clamp time and bypass time were
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INTRODUCTION
The arterial switch operation (ASO) has become the procedure of choice for the transposition of great arteries (TGA) and double outlet right ventricle (DORV) (Taussig – Bing anomaly). Since the first successful ASO reported by Jatene and his colleges in 1975(1)Error! Bookmark not defined., there have been a steadily improvement in diagnosis, surgical techniques, and peri-operative management. The results have been
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improved and the reported mortality has fallen to the range of 0% -6% even when the complex group is included
(2, 3, 4, 5)
. However, the anatomic variation of the coronary
artery, combined arch anomalies, low birth weight and age presented over 4 weeks are still considered as a risk factors (2, 4, 5, 6).
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PATIENTS AND METHODS
A retrospective review of the clinical database system of the children’s
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cardiovascular program (Deutsches Herzzentrum, Berlin) between august 2012 an October 2015 for all patients underwent ASO for D-TGA or DORV with exclusion of patients who underwent double switch procedure. Hospital charts, echocardiography and cardiac catheterization data and operative reports were reviewed. There were 85 patients underwent ASO with median age 9 days, range (3 – 587) days. Morphologically, Simple TGA: 54(63.5%), TGA with ventricular septal defect (VSD): 13(15.3%), Conotruncal or arch abnormality: 18(21.2%), DORV: 6(7.1%), Side by side great vessels: 6 (7.1%).
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All patient underwent ASO with median sternotomy incision and the use of CPB and hypothermia, hypothermic circulatory arrest is not used. Autologous pantaloons shaped lightly fixed pericardium in glutaraldehyde is used, to make it easier to manipulate during the operation.
trap door technique in coronary artery button
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translocation with cold multi-dose Brett Schneider cardioplegia is used (cardioplegic protocol: starting dose with 30 ml/kg for 30 to 40 mins and then 20 ml/kg every 30 to 40 mins)
The operative variables included the coronary patterns (usual coronary pattern
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(1LCx, 2R), retro pulmonary course patterns, intramural course, mono-coronary ostium and other coronary artery patterns), simultaneous operative procedure other than ASO;
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(aortic arch or coarctation repair , left ventricular outflow tract(LVOT) or right ventricular outflow tract (RVOT) resection, valve repair, pulmonary arterioplasty), ischemic time , bypass time , amount of cardioplegia in ml per Kg per 30 minutes and delayed sternal closure.
Postoperative data included highest inotropic score in the first 48Hr. We considered inotropic score more than 20 as a high inotropic score. We had calculated the
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inotropic score using the following formula [ IS = (100× epinephrine dose µg / kg / minute) + (100× nore-epinephrine dose µg /kg/ minute) +(10× milrinone dose µg / kg / minute)](7). Postoperative data included also bleeding as amount per Kg in the first 24Hr ;coronary events suspected by ECG changes, ventricular wall hypokinesia or increase of
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myocardial Troponin ; highest plasma lactic acid in the first 72 hr; presence of capillary leak syndrome judged by increased volume needs and presence of generalised oedema ;
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infection (bronchopneumonia or wound infection) judged by clinical examination and increase in infection parameters ; neurological insult screened by general neurological examination and further radiological investigation if needed ; need of mechanical circulatory support (ECMO) ; length of ventilation in days (early extubation as ≤ 3 days , moderate need for mechanical ventilation from 4 to 6 days and late extubation ≥ 7days) ; length of stay in cardiac intensive care unit (≤ than 7 days or more than 7 days) ; the hospital lengths of Stay (classified into ≤ 15 days or more than 15 days) ; time for secondary sternal closure in days ; need for early reoperation or catheter intervention and mortality.
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We considered need for ECMO, occurrence of coronary events and reoperation or catheter intervention as strong index of increased morbidity (high morbidity group). We defined early Mortality as death within the hospital stay or within 30 days
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from the operation. We have examined the statistical significance or tendency in each of the preoperative and operative variables, which correlate with patients who had unfavorable outcome (high morbidity group or mortality) to the whole population.
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Statistical analysis was performed using IBM© SPSS© for Windows (release 22.0,IBM Company). All continuous parameters are given as median and range. Categorical data are summarized as frequencies and percentages. For comparisons
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between patient groups the Mann-Whitney-U test was used in case of continuous parameters and Chi² Test or Fisher’s exact test for categorical data. The influence of demographic, preoperative and intraoperative variables was evaluated by logistic regression.
All tests were performed two-sided with a threshold for statistical
RESULTS:
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significance of 5 % .All analysis was exploratory in nature.
Preoperative, operative and postoperative data were summarized in tables 1, 2, 3,
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respectively.
Coronary events were noticed in 5 patients; 3 cases had a usual coronary artery patterns and 2 cases had intramural course. All of them underwent diagnostic coronary
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angiography except one case that died intraoperatively. No stenosis or disturbance in coronary blood flow was noted in 2 cases, in the other 2; mild stenosis at the beginning of the LAD was found in one of them while the other one had LT coronary ostium stenosis and Intra operative coronary artery dissection. 2 cases needed ECMO. Reoperations or catheter interventions were required in 17 patients (20%): 5 secondary chest re-openings, 4 cardiac catheters for SVC thrombosis, re-explorations for bleeding in 2 cases, ECMO implantations in 2 cases, one case required cardiac catheter for residual VSD, one case required balloon dilatation of Aortic Coarctation, one case re-
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operated for coronary artery re-implantation, one case required diaphragmatic plication and pacemaker implantation in one patient for permanent heart block. There were 3 (3.5%) early deaths in our study. The cause in one case was low
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cardiac output mostly related to inadequate myocardial protection in long ischemic time; ECMO was used but developed capillary leak, chest infection, sepsis and death after 64 days. In the other 2 cases, coronary events and postoperative myocardial ischemia were evident, so complex coronary patterns (in one of them, the two coronary ostia were arising from sinus 2 close to the commissure with an intramural course of the left
LCA) were implicated in the mortality.
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coronary artery (LCA), in the other; high left coronary ostium and intramural course of
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Statistical analysis revealed that several risk factors were associated with unfavorable outcome (high morbidity and mortality) in patients underwent arterial switch operation. We found that preterm babies had tendency to have unfavorable outcome (Pvalue=0.60) and also low birth weight patients (P-value=0.03). From the preoperative variables there was no correlation between urgency to operation or preoperative surgical intervention and the unfavorable outcome. We had found a statistical significance in
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patients who had took preoperative corticosteroid to have unfavorable outcome (Pvalue=0,046). From morphological variables there was tendency of patients with TGA with VSD or patients with DORV-TGA (Taussig Bing anomaly) to have unfavorable outcome (P=0.07, 0.06, respectively). Side by side presentation was statistically
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insignificant as regarding poor outcome. The intramural course and other coronary abnormalities were statistically significant (P-value=0.04) but retropulmonary course and
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mono-coronary ostium had no correlation to unfavorable outcome. There was no correlation between having simultaneous operative procedure and
the unfavorable outcome (P-value=0.9). Prolonged ischemic time was strongly statistically significant predictor for
unfavorable outcome (P-value=0.000). However, long bypass time and small amount of cardioplegia have a statistical tendency to unfavorable outcome (P-value= 0.07. 0.09). There was a strong statistical correlation between the increase in the cardiopulmonary bypass time and both the prolongation of the ventilation time and
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increasing the amount of postoperative bleeding (P-value =0,000), in other hand, it has no statistical correlation to the postoperative increase in the lactate value (P-value=0.88). The increase in the ischemic time had a strong statistical correlation with the
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increased inotropic support in the postoperative period (P-value=0.002). There was no statistically significant correlation between the amount of the given cardioplegia and the need of inotropic support in the postoperative period (P-value=0.6). Also, there was no statistical correlation between the use of preoperative corticosteroid
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and the occurrence of postoperative infection or capillary leak syndrome. (P-value= 0.2,
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0.6, respectively).
DISCUSSION
Survival of patients with D-TGA has improved since the introduction of ASO; indications for ASO have been extended to include more complex anatomic subsets
(8)
.
Though ASO seems to be the operation of choice for patients with complex D-TGA, differential survival for patients with complex TGA has been demonstrated
(9, 10)
.
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Previous risk factor analyses have identified “complex D-TGA” and TGA with VSD as risk factors for mortality, but additional details are needed for accurate preoperative risk stratification, operative planning, and family counseling. Central to surgical planning decisions is the ability to distinguish between patients who have uncorrectable anatomy
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and those whose anatomy provides technical difficulty and consequent morbidity associated with longer cardiopulmonary bypass and circulatory arrest times (8,11).
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In our study there were 85 patients underwent ASO with median age 9 days,
range (3 – 587) days. There were 3 (3.5%) early mortalities, with coronary events related myocardial ischemia implicated in 2 cases as the cause of death and postoperative low cardiac output unrelated to coronary events in the third case. This was more or less comparable to data from other centers as that of Pretre and his colleagues (6% early mortality) (12), Prandstetter and co-workers (1.75%) (3), Fricke and co-workers (2.8%) (13) and 2.2% early mortality in shim and his associates (14); in all of them the most common cause of early mortality was coronary events related myocardial ischemia.
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In our study there were 6 preterm babies (7.1%). Statistical analysis revealed that there was a statistical tendency near significance (p value = 0.6) of this group (preterm babies) to have unfavorable outcome (mortality or ECMO need, coronary events and reoperation) which was also consistent with Blume and his colleagues in their study that
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had 6 preterm babies among their arterial switch patients with a strong statistical significance for mortality (p value =0.03) (8).
The median age of our patients at time of ASO was 9 days, (3 – 587); 80% of them underwent ASO in the first 2 weeks, 17 patients > 2 weeks, 4 patients within the
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third week and 13 patients in a higher age group especially in DORV- TGA group or in patients with TGA -VSD and previous banding. There was no statistical significance
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correlates bad outcome with different age groups underwent ASO. Earlier ASO may have a Neurodevelopmental benefit and may reduce hospital morbidity, complications, and cost (15). One study supported 3 days of age as the ideal time for an ASO(16) ; even more, other studies suggested that ASO can be safely performed as early as within hours of birth using autologous umbilical cord blood to prime the bypass circuit(17,18). On the other hand, the surgical management for TGA with intact ventricular septum (TGA/IVS)
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beyond the age of 3 weeks is still controversial. The concern regarding deconditioned LV and its inability to handle the systemic circulation was always considered a contraindication for ASO beyond the age of 3 weeks
(19)
. But some recent studies as
reported by Ismail and his colleagues revealed that ASO for patients with TGA/IVS still
conditioned
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can be tolerated beyond the first month of life provided that the LV remains well (20).
Also, Nicholas Kang and co-workers in their work on 380 patients
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underwent arterial switch for TGA/IVS; 275 patients were younger than 3 weeks at the time of surgery (early switch group); and 105 patients were 3 weeks or older (range, 21 to 185 days) (late switch group). They showed no difference in outcome in terms of inhospital mortality (5.5% versus 3.8%) or need for mechanical circulatory support (3.6% versus 5.7%) between early and late switch groups. However, duration of postoperative ventilation (4.9 versus 7.1 days, P=0.012) and length of postoperative stay (12.5 versus 18.9 days, P=0.001) were significantly prolonged in the late switch group (21). Other older study performed in Cairo university concluded that the ASO is still the best solution in dealing with neonates with TGA/IVS, As They reported gradual decline in the total
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annual mortality from 49.4% after the first year down to 25.9% after the third year which reflects improvement in the learning curve in 3 areas; better patient selection, perioperative management and gaining more experience as regards surgical techniques, they suggested a new policy to start tackling infants with TGA/IVS with the rapid 2-stage
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(ASO) despite the apparent higher mortality after (ASO) at this time (26 ).
Regarding benefits from obtaining preoperative corticosteroid in patients undergoing arterial switch operation especially in neonatal period we had found no benefit from obtaining a dose from preoperative corticosteroid but moreover we found a
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statistical significant in this group who took preoperative corticosteroid to have unfavorable outcome (p value=0.046) which was consistent with what found by Eric M.
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Graham and his colleagues (22).
Regarding the correlation between coronary anatomy and early outcome, we found a statistical significance correlates of intramural course to have increased risk of mortality or bad outcome (p value= 0.042). This was also found in other studies from Wong and its colleagues
(23)
and Error! Bookmark not defined.Xinxinchen and his
associates who reported a strong relation between intramural coronary artery course and (24).
On the other side, Blume and his co-workers reported that coronary
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early mortality
artery pattern was not associated with an increased risk of death. Compared with usual coronary anatomy pattern, however, inverted coronary patterns and single right coronary patterns were associated with increased incidence of delayed sternal closure (p = 0.003) (8)
Also, Thrupp and his
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and longer duration of mechanical ventilation (p = 0.008)
colleagues in a recent study with 18 patients had intramural CA out of 215 ASO in this
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cohort (8.4%). Early mortality for patients with IMCA was 1 of 18 (5.6%) compared with 6 of 197 (3%) for those without IMCA (p = 0.46). One intramural coronary artery (IMCA) patient was lost to follow-up. The remaining 16 were alive and asymptomatic (6) We did not found a statistical significance for unfavorable outcome concerning
the retro pulmonary course pattern or the monocoronary ostia patterns (p value is 0.33, 0.30, respectively) unlike what was found by Wong and his colleagues
(23)
Error!
Bookmark not defined. and Blume and his associates (8). We found that there was statistically significant tendency to have unfavourable outcome in the group of TGA +DORV (p value=0.060) and TGA with VSD (p value=
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0.075) as found in other studies by Prifti and his colleagues as they found by multivariate analysis that complex TGA (P=0.007), VSD (P=0.032), coronary anomalies (P=0.004), aortic coarctation or hypoplastic aortic arch (P=0.021), left ventricular outflow tract obstruction (LVOTO) or moderate PAS (P=0.041) as strong predictors for poor
his colleagues
(25)
(25)
. However, unlike what was found by Prifti and
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reoperation-free cumulative survival
we did not found a statistically significant correlation between
simultaneous operative repair of aortic arch obstruction or left ventricular tract obstruction and mortality or bad outcome (p value = 0.980).
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Concerning ischemic time, bypass time and the given amount of cardioplegia, we found that there was strong statistical significance of having unfavourable outcome with
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prolongation of the ischemic time (p value =0.000) and statistical significant tendency towards having unfavourable outcome with increased bypass time (p value= 0.079) and using smaller amounts of cardioplegia per kg per 30 minutes (p value= 0.097), that was like what is found by Stoica and co-workers and Blume and his colleagues (5, 8). The bypass time was a major determining factor in increasing the postoperative bleeding (p value=0.000) and also in increasing the length of mechanical ventilation (p
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value =0.000) but it did not affect the postoperative lactate value in the first 3 days (Pvalue=0.88).
There was a strong statistical significant correlation between the increase in the ischemic time and increased postoperative inotropic support (P-value = 0.002), but on the
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other hand there was no correlation between the given amount of cardioplegia and the need of inotropic support in the postoperative period (p value =0.623). These results were
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consistent with what were found by others studies (2, 8, 9, and 10).
CONCLUSIONS:
The arterial switch operation can be performed in the current era without excess mortality. Even more, complex TGA now can be performed with low incidence for mortality and morbidity in the early postoperative period. Also, simultaneous aortic arch repair can be done at time of the arterial switch operation with no extra mortality. Preoperative corticosteroids carry no extra
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benefit for the patients. Prematurity, low birth weight, Taussig-Bing anomaly, intramural coronary artery course and some other coronary abnormalities, longer aortic cross clamp time and bypass time are still risk factors for
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unfavourable outcome. Statistics are done by Mrs. Julia stein statistician at berlin heart center email :
[email protected]
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4. Soszyn N1, Fricke TA, Wheaton GR, Ramsay JM, d'Udekem Y, Brizard CP, and Konstantinov IE. Outcomes of the arterial switch operation in patients with Taussig-
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6. Thrupp SF, Gentles TL, Kerr AR, and Finucane K. Arterial switch operation: early and late outcome for intramural coronary arteries. Ann Thorac Surg. 2012;94(6):2084– 90. doi:10.1016/j.athoracsur. 2012. 07.013.
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8. Blume ED, Altmann K, Mayer JE, Colan SD, Gauvreau K, and Geva T. Evolution of risk factors influencing early mortalityof the arterial switch operation. J Am CollCardiol 1999;33:1702–9. 9. Brown JW, Park HJ, and Turrentine MW. Arterial switch operation:factors impacting
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Y, Richardson
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16. Anderson BR, Ciarleglio AJ, Hayes DA, Quaegebeur JM, Vincent JA, and Bacha EA. Earlier arterial switch operation improves outcomes and reduces costs for neonates with transposition of the great arteries. J Am CollCardiol 2014;63: 481–7
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17. Nevvazhay T, Chernogrivov A, Biryukov E, Biktasheva L, Karchevskaya K, Sulejmanov S, Kalinicheva J, Artemiev N.. Arterial switch in the first hours of life; no need for Rashkind septostomy? Eur J Cardiothoracic Surg. 2012;42:520–3 18. Chasovskyi K, Fedevych O, Vorobiova G, Zhovnir V, Maksimenko A, Boychenko
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for the primary arterial switch operation beyond the age of 3 weeks. Pediatr Cardiol.
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22. Eric M Graham, Andrew M Atz, Ryan J Butts, Nathaniel L Baker, Sinai C Zyblewski, Rachael L Deardorff, Stacia M DeSantis, Scott T Reeves, Scott M Bradley, and Francis G Spinale. Standardized preoperative corticosteroid treatment in neonates undergoing cardiac surgery: results from a randomized trial.
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Cardiovasc Surg 2011 Dec 20; 142(6):1523-9. 23. Wong SH, Finucane K, Kerr AR, O’Donnell C, West T, Gentles TL. Cardiac outcome
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up to 15 years after the arterial switch operation. Heart Lung Circ 2008;17:48–53 24. Xinxin Chen,
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26. M. Aboul Ezz, M. Fawzy Badr El-Din, H. Hamza S. El-Hefnawy, M. Abdel Rabel Raouf and H Shawky. Surgical Treatment of D-Transposition of the Great Arteries in Neonates and Infants. A Pioneer Egyptian Experience and a Protocol to Start
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with. J Egypt Soc Cardiothorac Surg 1997; 5 (1): 21-40.
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TABLES:
Table (1): Preoperative patient’s characteristics First week
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Age at operation in days (n=)
32 (37,6 %)
Gestational age (n=)
O2 saturation at operation
Simple TGA
54(63,5%)
Median
17 (20%)
9 r(3 – 587)
Full term
Preterm
79 (92,9 %)
6(7,1 %)
>=3Kg
Median
14 (16,5%)
71 (83,5%)
3,45 r (2,2 -11,3)
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Previous operative interventions Summary (n=)
>2 weeks
< 3Kg
Preoperative corticosteroid (n=)
Morphology Summary (n=)
36 42,4 %)
Not Urgent
Urgent
62 (72,9%)
23 (27,1%)
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Weight at operation in kg (n=)
Emergency (n=)
>1 week
Median 89 % r (70 - 97 %) No
Yes
73 (85,9%)
12 (14,1%)
No previous operative intervention 76 (89,4%)
Banding or B-T
TGA with VSD 13(15,3%)
Conotruncal or arch abnormality 18(21,2%)
Table (2): Intra-operative findings:
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Aortic arch or coarctation repair
6 (7,1%)
4 (4,7%) DORV 6(7,1%)
Side by side great vessels 6(7,1%)
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Simultaneous operative procedure Summary (n=)
Retro-pulmonary course 17 (20%)
Normal 58(68,2%)
Monocoronary ostium 4 (4,7%)
Aortic arch or coarctation repair 7 (8,2%)
Intramural course 3 (3,5%)
Median 104 r (75 – 310)
Bypass time (mins)
Median 202 r (141 – 600)
Amount of cardioplegia ml \ Kg \ 30 mins
Median 20 ml r (10 – 35) ml
No 62 (72,9%)
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Ischemic time (mins)
Delayed sternal closure (n=)
Yes 23 (27,1%)
TE D
Table (3): postoperative data: Highest inotropic score n first 48hr (n=)
≤ 20 59 (69,4%)
> 20 high 26 (30,6%)
Median 13 r (0,6 – 49)
Median 16 ml r ( 3,2 – 118) ml
Highest lactate value in 1st 72hr mg/dL (n=76)
Median 38 r (12 – 93)
AC C
EP
Bleeding in 1st 24hr \ Kg In ml
Need for ECMO
No 83
Coronary events (n=)
Infection (n=) Time for secondary sternal closure (in days)
Yes 2 5
Reoperation or catheter intervention (n=)
Capillary leak syndrome (n=)
Others pattern 9(10,6)
LVOTO or RVOTO repair or others 12 (14,1%)
RI PT
Coronary artery patterns Summary (n=)
17 (20%) No 59 (69,4 %)
Yes 25 (29,4%) 8 (9,4%) Median 4 r (1 – 8)
ACCEPTED MANUSCRIPT 16
ICU stay (in days) (n=)
Early extubation ≤3 32(37,7%)
Moderate need for MV 4–6 days 26 (30,6 %)
≤ 7days 50(58,8%)
> 7 days 34 (40%)
Neurological insult (n=)
3 ≤ 15 days
>15 days
66(77,7%)
18 (21,2%)
M AN U TE D EP AC C
Median
4 r (1 – 64)
Median 7 r (2 – 64) Median 13 d (8–64)
SC
Hospital stay(in days) (n=)
Delayed extubation ≥7 26(30,6%)
RI PT
Ventilation time (indays)(n=)
