99 - Variation in Time to Extubation and Length of Stay after Mandibular Distraction Osteogenesis for Infants with Micrognathia among Children’s Hospitals

Poster Number: 99
Publication Number: 99.438

Kuan-Chi Lai, Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA., Los Angeles, CA, United States; Cynthia Gong, Children's Hospital Los Angeles, Los Angeles, CA, United States; Philippe Friedlich, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States; Ashwini Lakshmanan, CHLA, Los Angeles, CA, United States

Background: Mandibular distraction osteogenesis (MDO) has become the mainstream surgical treatment for airway obstruction in patients with micrognathia. Few studies have investigated risk factors associated with prolonged mechanical ventilation after MDO. However, there is no standardized guideline for optimal time to extubation (TTE) after MDO and its effect on length of stay (LOS) is unknown.
 

Objective: To describe variations in TTE after MDO in infants with micrognathia among children’s hospitals and examine the impact of TTE on LOS after MDO.
 

Design/Methods: We analyzed a retrospective cohort of infants with micrognathia undergoing their first MDO surgery within 6 months of life who were discharged home from 2011-2020 from hospitals in the Pediatric Health Information System. Patients with tracheostomy before their first MDO encounter discharge were excluded and hospitals with fewer than 20 eligible patients were also excluded. Non-parametric tests were used for univariate analyses. Hierarchical generalized linear model with hospitals as random effects assessed the association of TTE after MDO on postoperative LOS adjusting for patient characteristics.

Results: 842 patients from 21 hospitals were eligible. Hospitals with median TTE >= 8 days did not have more patients with known risks of prolonged mechanical ventilation such as lower birthweight, preterm, intubated prior to MDO, or syndromic micrognathia (Table 1). TTE as displayed on a box plot (Figure 1A) demonstrated significant variations among hospitals (p < 0.001). However, there was no significant risk of reintubation within 10 days of extubation for hospitals with shorter TTE (Figure 1B, p=0.58). Postoperative LOS (median days [interquartile range]) for hospitals with median TTE < = 5 days was 19 [13-31], median TTE 6-7 days was 24 [17-36.5], and median TTE >= 8 days was 26.5 [19-35], p< 0.001. Adjusted regression model showed that an additional day on mechanical ventilator led to 1.33 days (95% CI: 1.08-1.59) of delay in discharge (Table 2). Patients with syndromic micrognathia and those who required intubation prior to MDO also were associated with longer postoperative LOS.Conclusion(s): Variations in TTE after MDO exists and has significant impact on postoperative LOS even after adjusting for patient case-mix. Although individual anatomy and postoperative distraction length may also influence the decision to extubate, this study demonstrates that hospital-level variations exist, likely reflecting provider preferences. Hospitals currently with longer median TTE may consider a standardized protocol for extubation for clinically appropriate patients.
Table 1: Patient Characteristics by Hospital Median Time to Extubation.
Figure 1a: Time to Extubation after MDO by Hospitals. Figure 1b: Reintubation Rates within 10 Days of Extubation by Hospitals.Hospitals (anonymized by alphabet letters) are arranged by their median time to extubation in the box plot (Figure 1a). The same order of hospitals are shown for the reintubation rates (Figure 1b) for ease of comparison.