(370010-49) Overnight Extubation in Pediatric Critical Care: Analysis of a National Quality Improvement Registry

Introduction: Overnight extubation (OE) in adults is associated with poor outcomes, but its safety is unknown in children. Avoidance of OE may needlessly prolong mechanical ventilation (MV). We aim to describe the frequency and outcome of OE using data from the National Virtual Pediatric Systems, a large multicenter quality improvement database.

Methods: We performed a retrospective cohort study analyzing children ≤18 years old who received at least 24 hours of MV while in a pediatric ICU (PICU) between 2010-2020. OE was defined as occurring from 7 PM-6:59 AM. For patients with multiple episodes of MV, only the first episode of MV was analyzed. We compared patient and hospital characteristics of patients undergoing daytime extubation (DE) and OE using Chi-square and Wilcoxon rank sum tests to identify factors associated with OE. We used multivariate regression models to identify associations between OE and extubation failure (defined as reintubation within 24 hours), hospital mortality, and ICU and hospital lengths of stay.

Results: We analyzed 99,788 patients (43% female, 55% aged < 2 yr, mean (SD) weight 20.2 (23.1) kg) cared for in 174 PICUs (70% with 24-hour attending physician coverage, 71% university medical school affiliated, 78% with residents, and 46% with PICU fellows). OE occurred in 14% of cases and varies by region (10% in the Northeast to 32% in the South). OE was associated with older age ( > 2 years), diagnosis of trauma, post-operative admission, non-cardiac diagnosis, 24-hour attending coverage, and PICU fellowship (p < 0.001). Compared to DE, OE was associated with increased mortality (OR 3.13; 95% CI 2.89-3.38) and shorter ICU length of stay among survivors (median (interquartile range), OE 3.9 (1.9-8.2) vs DE 6.9 (3.8-12.0) days, p < 0.001).

Conclusions: The frequency of OE in critically ill children in the US is low. The frequency of overnight extubation varies by PICU, with higher rates among units that have 24-hr attending physician and fellowship training. OE is associated with higher rates of mortality, but shorter ICU length of stay among survivors compared to DE.