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A Multivariable Model Predictive of Unplanned Postoperative Intubation in Infant Surgical Patients

Eisler, Lisa D. MD*; Hua, May MD*,†; Li, Guohua MD, DrPH*,†; Sun, Lena S. MD*,‡; Kim, Minjae MD, MS*,†

doi: 10.1213/ANE.0000000000004043
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures.

METHODS: In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012–2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve.

RESULTS: In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85–0.87) for the derivation cohort and 0.83 (95% CI, 0.82–0.85) for the validation cohort.

CONCLUSIONS: About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes.

From the *Department of Anesthesiology, Columbia University Medical Center, New York, New York

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York

Department of Pediatrics, Columbia University Medical Center, New York, New York.

Published ahead of print 5 February 2019.

Accepted for publication December 20, 2018.

Funding: L.D.E. is supported by an institutional training grant from the National Institutes of Health, T32GM008464-26. M.K. is supported by the National Center for Advancing Translational Sciences, National Institutes of Health through Grant Number KL2TR001874.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

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The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Address correspondence to Lisa D. Eisler, MD, Department of Anesthesiology, Columbia University Medical Center, 622 W 168th St, PH 5, Suite 505C, New York, NY 10032. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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