Incidence, Risk Factors, and Outcomes of Non-Extubation in the Operating Room Following Elective Pediatric Neurosurgery-A Prospective Observational Study.

Background: Studies on non-extubation after elective pediatric neurosurgery are limited. As non-extubation can contribute to adverse patient outcomes, there is a need to understand this problem better. We aimed to assess the incidence, risk factors, and impact of non-extubation in the operating room (OR) after elective pediatric neurosurgery.

Methods: This was a single-center, prospective, observational study conducted at a university hospital from February 2022 to November 2023 after ethics approval and study registration. We included patients aged below 18 years undergoing elective neurosurgery under general anesthesia. Non-extubation was defined as retention of the tracheal tube before leaving the OR. Data collected included age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, neurosurgical diagnosis, surgical procedure, comorbidities, presence of preoperative lower cranial nerve palsy, Cormack-Lehane grade, surgery duration, patient position, intraoperative complications, transfusion of blood products and colloids, fluid balance, neurological decline, in-hospital mortality, and durations of postoperative stay in the intensive care unit (ICU) and hospital.

Results: A total of 738 children were included in the study. The incidence of non-extubation was 13.01% (96/738). The predictors of non-extubation were higher ASA grade (odds ratio [OR] 2.86, 95% confidence interval [CI] 1.78-4.69, p < 0.001), preoperative lower cranial nerve palsy (OR 2.35, CI 1.23-4.43, p = 0.010), prolonged surgery (OR 1.45, CI 1.26-1.68, p < 0.001), occurrence of intraoperative complications (OR 4.89, CI 2.69-8.89, p < 0.001), and higher intraoperative blood transfusion rates (OR 2.46, CI 1.37-4.5, p = 0.002). Non-extubation in the OR was associated with postoperative neurological deterioration, higher in-hospital mortality, and prolonged ICU and hospital stay.

Conclusions: A significant proportion of children are not extubated immediately after elective pediatric neurosurgery. Higher ASA grade, lower cranial nerve palsy, prolonged surgery, intraoperative complications, and higher blood transfusion increase the risk of delayed extubation. Non-extubation in the OR is associated with poor postoperative outcomes of neurological decline, in-hospital mortality, and longer duration of hospital stay.