O1053: Identifying Predictors that Determine the Need for ICU-Level Care Following Elective Surgical Excision of Congenital Pulmonary Lesions in Children

Background: Planned ICU admission following elective congenital pulmonary airway malformation (CPAM) surgery is often arranged by default as lung resection is considered major surgery in the pediatric population. While routinely planning ICU admission for this cohort may mitigate severe post-operative complications, ICU-level care ultimately may not be needed resulting in wasted resources and increased cost. There are no current guidelines in the literature regarding predictive factors of ICU-level needs following elective CPAM surgery. In our institution, we hypothesized that most patients admitted to the ICU following elective CPAM surgery did not utilize ICU level care. Therefore, patients undergoing elective CPAM resection were evaluated to determine criteria necessitating post-operative ICU-level intervention, thereby justifying ICU admission.

Methods: Children undergoing elective CPAM resection between December 2016- December 2023 were retrospectively studied to determine factors associated with ICU level intervention. Factors analyzed included age, weight, diagnosis, extent of surgical resection, operative approach, EBL, transfusion utilization, OR room duration, and ability to extubate in the OR. ICU-level interventions were defined as hemodynamic instability, vasopressor use, ventilator/CPAP use, reintubation, ECMO, and re-operative intervention. Statistical analyses were performed using the Wilcoxon rank sum test and Fisher’s exact test.

Results: 87 children met inclusion criteria with a median age of 0.81 years at the time of operation (range: 0.2, 17.5 years). Diagnoses included: CPAM (n=37), intralobar (n=32) and extralobar (n=9) sequestrations, congenital lobar emphysema (n=1), bronchogenic cyst (n=7), pleuropulmonary blastoma (n=2), and other diagnosis (n=3). Four of the 87 patients had two separate diagnoses requiring extended surgical intervention. 63.2% (n=55) underwent lobectomy. 73.6% (n=64) were admitted to the ICU post-operatively and 26.4% (n= 23) to the floor. Of the patients admitted to the ICU only 12.5% (n=8) received ICU-level intervention and 87.5% (n=56) did not. No patients admitted to the floor post-operatively required transfer to the ICU. Predictors of ICU-level intervention included thoracoscopic converted to open surgery (P=0.023), higher total EBL (P=0.028) and EBL mL/kg (P=0.018), longer OR room duration (P=0.027), and inability to extubate at the end of the OR case (P= 0.001). Only 1 patient had an unexpected adverse event due to heparin-induced thrombocytopenia which was related to the heparin exposure and not the operative procedure per se. Extralobar sequestration was predictive of floor admission (P=0.013).

Conclusion: Only 8 (12.5%) of children undergoing elective congenital pulmonary airway malformation required ICU intervention following admission to the ICU and no patients admitted to the floor needed transfer to the ICU. Predictive factors warranting ICU-level intervention post-operatively include operative approach, estimated blood loss, OR room duration, and ability to extubate at the end of the surgical case. We conclude that customizing patient disposition based on these factors could minimize ICU admission rate by 87.5% while maintaining patient safety.