Time-directed extubation (fast-track) protocols may decrease length of stay and cost
but data on operating room (OR) extubation is limited. The objective of this study
was to compare the outcomes of extubation in the OR versus fast-track extubation within
6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases
(2011–2021) who were extubated within 6 hours were identified from a regional STS
quality collaborative. Patients were stratified by extubation in the OR versus fast
track. Propensity score matching (1:n) was performed to balance baseline differences.
Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation
cases and 899 fast track cases were well balanced. The rate of reintubation was higher
for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899
(0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487
(3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs
6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation
and reoperation due to bleeding, but lower resource utilization.Future research exploring
predictors of extubation readiness may be required prior to widespread adoption of
this practice.
Graphical abstract
Graphical Abstract
Keywords
Abbreviations:
STS (Society of Thoracic Surgeons), VCSQI (Virginia Cardiac Services Quality Initiative), OR (operating room), ICU (intensive care unit), ORE (operating room extubation), CABG (coronary artery bypass graft), FTE (fast-track extubation)To read this article in full you will need to make a payment
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References
- Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial.J Thorac Cardiovasc Surg. 1996; 112: 755-764
- Fast track and ultra-fast track cardiac surgery recovery care.in: Cheng DC Martin J David T Evidence-Based Practice in Perioperative Cardiac Anesthesia and Surgery. Springer Cham, 2021
- Patients should be extubated in the operating room after routine cardiac surgery: an inconvenient truth.TJ Thoracic Cardiovasc Surg Tech. 2021; 8: 95-99
- Fast-track cardiac care for adult cardiac surgical patients.Cochrane Database Systematic Rev. 2016; 9CD003587
- Randomized assessment of resource use in fast-track cardiac surgery 1-year after hospital discharge.J Am Soc Anesthesiol. 2003; 98: 651-657
The Society of Thoracic Surgeons. STS Quality Webinar Series. Prolonged Ventilation. Available at https://www.sts.org/learning-center/webinars. Accessed December 6, 2021.
- Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients.J Cardiothorac Vasc Anesth. 2005; 19: 282-287
- Comparison of immediate extubation versus ultrafast tracking strategy in the management of off-pump coronary artery bypass surgery.Ann Cardiac Anaesthesia. 2018; 21: 129
- The lack of benefit of tracheal extubation in the operating room after coronary artery bypass surgery.Anesthesia Analgesia. 2000; 91: 776-780
- Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: a randomized clinical trial.Anesthesiology and Pain Medicine. 2018; 8: 5
- The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.J Cardiothorac Vasc Anesth. 2010; 24: 780-784
- Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109
- Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299
- Coronary artery bypass grafting bundled payment proposal will have significant financial impact on hospitals.J Thorac Cardiovasc Surg. 2018; 155: 182-188
The Society of Thoracic Surgeons. https://www.sts.org/registries-research-center/sts-national-database/adult-cardiac-surgery-database/data-collection. Accessed December 6, 2021
- The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 2—statistical methods and results.Ann Thorac Surg. 2018; 105: 1419-1428
- Correlation coefficients: appropriate use and interpretation.Anesth Analg. 2018; 126: 1763-1768
Schreiber-Gregory DM. Multicollinearity: what is it, why should we care, and how can it be controlled? https://support.sas.com/resources/papers/proceedings17/1404-2017.pdf. Accessed February 9, 2022.
- The challenge of achieving 1% operative mortality for coronary artery bypass grafting: a multi-institution Society of Thoracic Surgeons Database analysis.J Thorac Cardiovasc Surg. 2014; 148: 2686-2696
- Multicenter evaluation of high-risk mitral valve operations: implications for novel transcatheter valve therapies.Ann Thorac Surg. 2014; 98: 2032-2038
- Effect of positive end-expiratory pressure on excessive mediastinal bleeding after cardiac operations: a controlled study.J Thorac Cardiovasc Surg. 1983; 85: 864-869
- Prophylactic positive end-expiratory pressure and reduction of postoperative blood loss in open-heart surgery.Ann Thorac Surg. 2002; 74: 1191-1194
- Predictors of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. 2017; 154: 1656-1665
- Success and failure of fast track extubation in cardiac surgery patients of tertiary care hospital: one year audit.J Pakistan Med Assoc. 2009; 59: 154
- Risk factor analysis for fast track protocol failure.J Cardiothoracic Surg. 2013; 8: 1-6
- Minimally invasive cardiac surgery:a systematic review and meta-analysis.Int J Cardiol. 2016; 223: 554-560
- A propensity matched analysis of robotic, minimally invasive, and conventional mitral valve surgery.Heart. 2018; 104: 1970-1975
- Factors associated with safe extubation in the operating room after on-pump cardiac valve surgery.J Card Surg. 2016; 31: 274-281
- The Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding.Eur J Cardiothorac Surg. 2011; 39: 924-930
- Effect of adding postoperative noninvasive ventilation to usual care to prevent pulmonary complications in patients undergoing coronary artery bypass grafting: A randomized controlled trial.J Thorac Cardiovasc Surg. 2013; 146: 912-918
- A specialized post-anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial.Critical Care. 2014; 18: 1
- A multidisciplinary protocol-driven approach to improve extubation times after cardiac surgery.Ann Thorac Surg. 2018; 105: 1684-1690
- Multicenter international survey on the clinical practice of ultra-fast-track anesthesia with on-table extubation in pediatric congenital cardiac surgery.J Cardiothorac Vasc Anesth. 2019; 33: 406-415
Article info
Publication history
Published online: November 29, 2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding: This work was funded in part by a grant from the Cardiothoracic Surgery Trials Network of the National Institutes of Health Clinical Research and Implementation Skills Program under Award Number 2UM HL088925, as well as by the National Heart, Lung, and Blood Institute (grant T32 HL007849-21A1).
Disclosures: Dr. Ailawadi is a consultant and advisor for Medtronic, Inc; Edwards Lifescience; Abbott Laboratories; AtriCure and Cephea Valve Technologies. Dr. Joseph is a speaker for Angiodynamics. Dr. Yarboro has received honoraria for consulting and proctoring for Medtronic and has proctored for Abbott Laboratories.
Read at the AATS 102nd Annual Meeting, May 14-17, 2022, Boston, MA.
Classifications: Adult, Perioperative Management
IRB Approval/Informed Consent Statement: This study was exempt from review by the University of Virginia's Institutional Review Board due to the de-identified nature of the quality database (Protocol #19762).
Oral Presentation at the AATS 102nd Annual Meeting May 14-17, 2022 in Boston, MA.
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