Multidisciplinary Extubation Protocol in Cardiac Surgical Patients Reduces Ventilation Time and Length of Stay in the Intensive Care Unit

Electrical Impedance Tomography-based Ventilation Patterns in Patients after Major Surgery

Rationale: General anesthesia and mechanical ventilation have negative impacts on the respiratory system, causing heterogeneous distribution of lung aeration, but little is known about the ventilation patterns of postoperative patients and their association with clinical outcomes. Objectives: To clarify the phenotypes of ventilation patterns along a gravitational direction after surgery by using electrical impedance tomography (EIT) and to evaluate their association with postoperative pulmonary complications (PPCs) and other relevant clinical outcomes. Methods: Adult postoperative patients at high risk for PPCs, receiving mechanical ventilation on ICU admission (N = 128), were prospectively enrolled between November 18, 2021 and July 18, 2022. PPCs were prospectively scored until hospital discharge, and their association with phenotypes of ventilation patterns was studied. The secondary outcomes were the times to wean from mechanical ventilation and oxygen use and the length of ICU stay. Measurements and Main Results: Three phenotypes of ventilation patterns were revealed by EIT: phenotype 1 (32% [n = 41], a predominance of ventral ventilation), phenotype 2 (41% [n = 52], homogeneous ventilation), and phenotype 3 (27% [n = 35], a predominance of dorsal ventilation). The median PPC score was higher in phenotype 1 and phenotype 3 than in phenotype 2. The median time to wean from mechanical ventilation was longer in phenotype 1 versus phenotype 2. The median duration of ICU stay was longer in phenotype 1 versus phenotype 2. The median time to wean from oxygen use was longer in phenotype 1 and phenotype 3 than in phenotype 2. Conclusions: Inhomogeneous ventilation patterns revealed by EIT on ICU admission were associated with PPCs, delayed weaning from mechanical ventilation and oxygen use, and a longer ICU stay.

Extubation in the Operating Room After Coronary Artery Bypass Graft Surgery Reduces Hospital Stay

OBJECTIVES

The aim of this analysis was to compare the effect of extubating in the operating room (OR) versus and the intensive care unit (ICU) among patients undergoing coronary artery bypass grafting (CABG).

DESIGN

A retrospective cohort analysis.

SETTING

Ten cardiac referral hospitals in Latin America; participants of the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II).

PARTICIPANTS

The database included a total of 4,015 patients who underwent primary and isolated CABG surgery and were ≥18 years old, of whom 205 patients were extubated in the OR.

INTERVENTIONS

The analysis was made after a propensity score matching (PSM) adjustment in the population sample of patients extubated in the OR and ICU by the following variables: sex, age, body mass index, smoking, type of surgery, chronic obstructive pulmonary disease, preoperative atrial fibrillation, cardiopulmonary bypass time, preoperative creatinine, and preoperative left ventricular ejection fraction.

MEASUREMENTS AND MAIN RESULTS

This study focused on the analysis of the ICU and hospital length of stay, need for reintubation, morbidity, and mortality. After PSM, 402 patients were analyzed. Both groups had similar baseline characteristics, such as age (p = 0.132), sex (p = 1.00), and estimated risk of prolonged ventilation (>24 hours, p = 0.168); however, the median ventilation time was significantly shorter in the group extubated in the OR compared to the ICU group (5.67 hours v 17.55 hours, p < 0.001). The group of patients extubated in the ICU had a longer postoperative stay (7.54 ± 3.40 days v 6.41 ± 2.91 days, p < 0.001) and longer total hospitalization time (11.49 ± 5.70 days v 10.36 ± 5.72, p = 0.013) compared to those extubated in the OR. The authors did not observe a significant difference in the need for reintubation, morbidity, or mortality rates among the evaluated groups.

CONCLUSIONS

In the REPLICCAR II database, extubation performed in the OR was associated with a reduced length of postoperative and total hospital stays compared to extubation in the ICU.

A Retrospective Pilot Comparison Trial Investigating Clinical Outcomes in Cardiac Surgical Patients Who Received Sugammadex Reversal During 2018 to 2021

OBJECTIVES

To compare the number of eligible urgent and elective cardiac surgical patients who could be extubated successfully within 6 hours of surgery and who received sugammadex versus those who did not.

DESIGN

This retrospective pilot study compared outcomes in cardiac surgical patients undergoing cardiopulmonary bypass between 2018 to 2021 who received sugammadex versus those who did not.

SETTING

At a tertiary-care hospital in the Northshore of Chicago.

PARTICIPANTS

A total of 358 elective or urgent cardiac surgical patients who underwent cardiopulmonary bypass (by 1 cardiac surgeon) and were extubated within 24 hours of the end of surgery at Evanston Hospital in Evanston, IL, were included.

INTERVENTIONS

Data were examined in the following 2 groups of patients: those who were administered sugammadex and those who were not.

MEASUREMENTS AND MAIN RESULTS

After performing propensity matching for age, sex, body mass index, kidney or liver disease, the number of preoperative conditions (defined as the sum of the presence of the following medical conditions: diabetes, immunosuppressive disease, on home oxygen, on inhaled bronchodilator, or sleep apnea), number of patients who underwent elective or urgent surgery in each group, surgery time, cardiopulmonary bypass duration, number of intraoperative blood products, use of intraoperative midazolam and propofol, a statistically significant increase in the percentage of patients in the sugammadex group were extubated within 6 hours of the end of surgery versus those who did not receive sugammadex (96.67% v 81.33%, p = 0.0428). In addition, there was a statistically significant reduction in time to extubation (hours) (4.72 ± 2.92) v (3.57± 1.96 p = 0.0098) in the sugammadex group. All other outcomes did not meet statistical significance.

CONCLUSION

This retrospective study suggested that using sugammadex reversal in cardiac surgical patients undergoing cardiopulmonary bypass may result in more patients meeting the Society of Thoracic Surgery benchmark extubation criteria within 6 hours of the end of surgery.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

OBJECTIVES

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.

INTERVENTIONS

An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.

MEASUREMENTS AND MAIN RESULTS

The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.

CONCLUSIONS

The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

The Spillover Effects of Quality Improvement Beyond Target Populations in Mechanical Ventilation

To assess the impact of a mechanical ventilation quality improvement program on patients who were excluded from the intervention.

DESIGN

Before-during-and-after implementation interrupted time series analysis to assess the effect of the intervention between coronary artery bypass grafting (CABG) surgery patients (included) and left-sided valve surgery patients (excluded).

SETTING

Academic medical center.

PATIENTS

Patients undergoing CABG and left-sided valve procedures were analyzed.

INTERVENTIONS

A postoperative mechanical ventilation quality improvement program was developed for patients undergoing CABG.

MEASUREMENTS AND MAIN RESULTS

Patients undergoing CABG had a median mechanical ventilation time of 11 hours during P0 ("before" phase) and 6.22 hours during P2 ("after" phase; p < 0.001). A spillover effect was observed because mechanical ventilation times also decreased from 10 hours during P0 to 6 hours during P2 among valve patients who were excluded from the protocol (p < 0.001). The interrupted time series analysis demonstrated a significant level of change for ventilation time from P0 to P2 for both CABG (p < 0.0001) and valve patients (p < 0.0001). There was no significant difference in the slope of change between the CABG and valve patient populations across time cohorts (P0 vs P1 [p = 0.8809]; P1 vs P2 [p = 0.3834]; P0 vs P2 [p = 0.7672]), which suggests that the rate of change in mechanical ventilation times was similar between included and excluded patients.

CONCLUSIONS

Decreased mechanical ventilation times for patients who were not included in a protocol suggests a spillover effect of quality improvement and demonstrates that quality improvement can have benefits beyond a target population.

A 3-hour fast-track extubation protocol for early extubation after cardiac surgery

Objectives

Early extubation after cardiac surgery improves outcomes and reduces cost. We investigated the effect of a multidisciplinary 3-hour fast-track protocol on extubation, intensive care unit length of stay time, and reintubation rate after a wide range of cardiac surgical procedures.

Methods

We performed an observational study of 472 adult patients undergoing cardiac surgery at a large academic institution. A multidisciplinary 3-hour fast-track protocol was applied to a wide range of cardiac procedures. Data were collected 4 months before and 6 months after protocol implementation. Cox regression model assessed factors associated with extubation time and intensive care unit length of stay.

Results

A total of 217 patients preprotocol implementation and 255 patients postprotocol implementation were included. Baseline characteristics were similar except for the median procedure time and dexmedetomidine use. The median extubation time was reduced by 44% (4:43 hours vs 3:08 hours; P < .001) in the postprotocol group. Extubation within 3 hours was achieved in 49.4% of patients in the postprotocol group compared with 25.8% patients in the preprotocol group; P < .001. There was no statistically significant difference in the intensive care unit length of stay after controlling for other factors. Early extubation was associated with only 1 patient requiring reintubation in the postprotocol group.

Conclusions

The multidisciplinary 3-hour fast-track extubation protocol is a safe and effective tool to further reduce the duration of mechanical ventilation after a wide range of cardiac surgical procedures. The protocol implementation did not decrease the intensive care unit length of stay.

Bilateral continuous erector spinae plane block for cardiac surgery: case series

Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain. The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses. This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution. All patients reported pain according to the numeric rating scale (NRS)  ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively. Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.

Fast tracking in cardiac surgery: is it safe?

Background

While fast track clinical pathways have been demonstrated to reduce resource utilization in patients undergoing cardiac surgery, it remains unclear as to whether they adversely affect post-operative outcomes. The purpose of this study was to determine the impact of fast tracking on post-operative outcomes following cardiac surgery.

Methods

In a retrospective study, all patients undergoing first-time, on-pump, non-emergent coronary artery bypass grafting, valve, or coronary artery bypass grafting + valve at a single centre between 2010 and 2017 were included. Patients were considered to have been fast tracked if they were extubated and transferred from intensive care to a step-down unit on the same day as their procedure. The risk-adjusted effect of fast tracking on a 30-day composite of all-cause mortality, stroke, renal failure, infection, atrial fibrillation, and readmission to hospital was determined. Furthermore, propensity score matching was used to match fasting track patients in a 1-to-1 manner with their nearest “neighbor” in the control group and subsequently compared in terms of 30-day post-operative outcomes.

Results

3252 patients formed the final study population (fast track: n = 245; control: n = 3007). Patients who were fast tracked experienced reduced time to initial extubation (4.3 vs. 5.6 h, p < 0.0001) and lower median initial intensive care unit length of stay (7.8 vs. 20.4 h, p < 0.0001). Fast tracked patients experienced lower 30-day rates of the composite outcome (42.4% vs. 51.5%, p = 0.008). However, following propensity score matching, fast tracked patients experienced similar 30-day rates of the composite outcome as the control group (42.4% vs. 44.5%, p = 0.72). After risk adjustment using multivariable regression modeling, fast tracking was predictive of an improved 30-day composite outcome (OR 0.75, 95% CI 0.57–0.98, p = 0.03).

Conclusion

Fast track clinical pathways was associated with reduced intensive care unit, overall length of stay and similar 30-day post-operative outcomes. These results suggest that fast tracking appropriate patients may reduce resource utilization, while maintaining patient safety.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01815-9.

Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative

Objective

Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure.

Results

We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).

SLL-PEEP Ventilation to Improve Exposure in Minimally Invasive Right Anterolateral Minithoracotomy Aortic Valve Replacement

OBJECTIVE

An accepted landmark to assess feasibility of surgical aortic valve replacement (SAVR) via right anterolateral minithoracotomy (RALT) is the aortic-midpoint to right-sternal-edge distance. We aimed to evaluate single left lung positive-end-expiratory-pressure (SLL-PEEP) ventilation inducing an intraoperative rightward shift of the ascending aorta to improve exposure.

METHODS

Nineteen patients with aortic stenosis undergoing SAVR via RALT were prospectively analyzed. SLL-PEEP ventilation (20,395 cmH₂O) via a double-lumen endotracheal tube was applied immediately before transthoracic aortic cross-clamping, thereby inducing rightward shift of the ascending aorta to enhance exposure. We analyzed preoperative computed tomography (CT) reconstructions and intraoperative video recordings. Primary endpoint was extent of rightward shift induced by SLL-PEEP ventilation; secondary endpoints were procedure times and safety events.

RESULTS

Mean age was 61 ± 14.8 years and 6 of 19 (31.6%) were female. Mean EuroSCORE II was 0.81% ± 0.04%, STS-PROM was 1.13% ± 0.74%, and mean aortic rightward shift induced by SLL-PEEP ventilation was 10.32 ± 4.14 mm (4 to 17 mm; P = 0.003). Median shift in the group considered suitable for the RALT approach by preoperative CT-scan evaluation was 14.2 mm (IQR 11) and in the less suitable group 11.5 mm (IQR 5). Mean procedure time was 167 ± 28.9 min, CPB time was 105.7 ± 18.4 min, and cross-clamp time was 64.5 ± 13 min. Fifteen patients (79%) received SAVR via RALT with implantation of a bioprosthesis, whereas a rapid-deployment-prosthesis was used in 4 patients (21%). Ten of 19 (53%) patients who were classified as less suitable preoperatively received SAVR via RALT after SLL-PEEP ventilation. No strokes were observed.

CONCLUSIONS

The SLL-PEEP ventilation maneuver during SAVR via RALT significantly enhances aortic exposure. There were no safety events associated with this maneuver and we were able to demonstrate significant rightward aortic shift in every single patient.

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery

BACKGROUND

Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization.

METHODS

Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI.

RESULTS

Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018.

CONCLUSIONS

Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.

The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients

BACKGROUND

The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown.

METHODS

We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention.

RESULTS

Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates.

CONCLUSION

We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.

Continuous ultrafiltration during extracorporeal circulation and its effect on lactatemia: A randomized controlled trial

Introduction

Hyperlactatemia occurs during or after extracorporeal circulation in the form of lactic acidosis, increasing the risk of postoperative complications and the mortality rate. The aim of this study was to evaluate whether continuous high-volume hemofiltration with volume replacement through a polyethersulfone filter during the extracorporeal circulation procedure decreases postoperative lactatemia and its consequences.

Materials and methods

This was a randomized controlled trial. Patients were randomly divided into two groups of 32: with or without continuous high-volume hemofiltration through a polyethersulfone membrane. Five patients were excluded from each group during the study period. The sociodemographic characteristics, filter effects, and blood lactate levels at different times during the procedure were evaluated. Secondary endpoints were studied, such as the reduction in the intubation time and time spent in ICU.

Results

Lactatemia measurements performed during the preoperative and intraoperative phases were not significantly different between the two groups. However, the blood lactate levels in the postoperative period and at 24 hours in the intensive care unit showed a significant reduction and a possible clinical benefit in the hemofiltered group. Following extracorporeal circulation, the mean lactate level was higher (difference: 0.77 mmol/L; CI 0.95: 0.01–1.53) in the nonhemofiltered group than in the hemofiltered group (p<0.05). This effect was greater at 24 hours (p = 0.019) in the nonhemofiltered group (difference: 1.06 mmol/L; CI 0.95: 0.18–1.93) than in the hemofiltered group. The reduction of lactatemia is associated with a reduction of inflammatory mediators and intubation time, with an improvement in liver function.

Conclusions

The use and control of continuous high-volume hemofiltration through a polyethersulfone membrane during heart-lung surgery could potencially prevent postoperative complications. The reduction of lactatemia implied a reduction in intubation time, a decrease in morbidity and mortality in the intensive care unit and a shorter hospital stay.

A multidisciplinary approach to reducing ventilator-associated events in a busy urban hospital

Acute care hospitals are requested to perform ongoing surveillance of all patients undergoing mechanical ventilation for ventilator-associated events (VAEs), a serious and often devastating complication of the life-saving modality. Poor performance metrics in VAE rates were recognized at a tertiary care hospital in Hartford, Connecticut and as a result, a multidisciplinary team was developed in 2015 to analyze hospital and system data. The program utilized a multifaceted approach to reliably identify and subsequently prevent VAEs.

Implementing a Weaning Protocol for Cardiac Surgery Patients Using Simulation: A Quality Improvement Project

BACKGROUND

Mechanical ventilation is the standard of care after cardiac surgery, but it imposes physiologic and psychological stress on patients. The Society of Thoracic Surgery recommends 6 hours as the goal for extubation, but 60% of our patients were not meeting this metric.

OBJECTIVES

The objectives of this project were to decrease cardiac surgery patients' ventilation hours and intensive care unit length of stay using a ventilator weaning protocol.

METHODS

An evidence-based ventilator weaning protocol was developed, and nurses were prepared for its implementation using a simulation education program.

RESULTS

Ventilator hours were reduced from 7.74 to 6.27 (t = 2.5, P = .012). The percentage of patients extubated in 6 hours increased from 40% to 63.5% (χ = 7.757, P = .005). There was no statistically significant decrease in cardiovascular intensive care unit length of stay (17.15 to 15.99, t = 0.619, P = .537). Nurses' scores on a knowledge test increased significantly from pre (6.11) to post (7.79) (t = -5.04, P < .001). Their perception of confidence increased in weaning from pre (median, 4; IQR, 4,4) to post (median, 4; interquartile range [IQR], 4,5), z = -2.71, P = .007, and also in using the protocol from pre (median, 4; IQR, 3,4) to post (median, 4; IQR, 4,5) (z = -3.17, P = .002).

DISCUSSION

Using a nurse-led ventilator weaning protocol resulted in decreased ventilator hours for patients and increased knowledge and confidence for nurses.

Critical Care of Patients After Pulmonary Thromboendarterectomy

Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.

Ultra-fast-track extubation vs. conventional extubation after cardiac surgery in a cardiovascular reference centre in Colombia. A longitudinal study

INTRODUCTION

The fast track / ultra-fast-track protocols are techniques used to optimise the patient care process and a quick recovery after cardiac surgery. They are one of the mainstays of efficient practice. With their use, the length of hospital and intensive care unit (ICU) stays are reduced, with a direct impact on costs and the quality of the health service.

OBJECTIVE

To compare the length of stay in the ICU, length of hospital stay, and post-operative mortality in ultra-fast-track extubated (uFTE) patients and those with conventional extubation (CE) after cardiac surgery.

METHODS

Longitudinal, analytical, retrospective study was conducted, with the period between the time of surgery and discharge being included as the study period.

RESULTS

A total of 396 patients older than 18 years who required cardiac surgery were included, of whom 207 patients had (uFTE) and 189 had CE. Although the groups were not comparable due to the statistical differences found, when performing the multivariate adjustment, uFTE maintained its statistical independence and was associated with lower cardiovascular morbidity, such as myocardial ischaemia (95% CI: 0.37-0.86; P = .01) and lower post-surgical vasopressor requirement (95% CI: 0.18-0.49; P < .01). No significant differences were found in the length of hospital stay, ICU stay, or post-operative mortality in the ICU.

CONCLUSION

Implementing the uFTE strategy, decreases cardiovascular morbidity and vasopressor requirement. The change to uFTE should be accompanied by changes in models and practices in patient recovery to standardised protocols. This study shows that uFTE did not reduce the length of ICU stay, hospital stay, or mortality.

Is routine extubation overnight safe in cardiac surgery patients?

OBJECTIVES

Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database.

METHODS

Records from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00.

RESULTS

A total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality.

CONCLUSIONS

Extubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight.

Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial

BACKGROUND

The use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery.

METHODS

This clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients' depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented.

RESULTS

Demographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001).

CONCLUSIONS

Combined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.

Incidence of Immediate Extubation After Pediatric Cardiac Surgery and Predictors for Reintubation

Objectives:

The objectives were to assess the incidence of immediate tracheal extubation in the operating room after pediatric cardiac surgery and to investigate predictors for subsequent reintubation.

Methods:

This is a single institutional retrospective study including all patients who had a cardiac operation with cardiopulmonary bypass from 2011 to 2016. Patients who required preoperative ventilator support, postoperative open chest, or mechanical support were excluded. Predictors for reintubation after immediate extubation were analyzed only for patients with stage II palliation for single ventricle physiology.

Results:

Nine hundred nine qualifying operations were identified. Immediate extubation was performed in 590 (64.9%) operations. A multivariable logistic regression model showed that the identities of anesthesiologist ( P = .0003), year of the operation performed ( P < .001), cardiopulmonary bypass time ( P < .001), and type of operations ( P < .001) were significantly associated with immediate extubation. Reintubation was significantly less frequent in patients with immediate extubation compared to those without (6.1% vs 15.0%; P < .001). A subgroup analysis for stage II palliation showed that reintubation after immediate extubation was significant for younger age (0.42 vs 0.54 years, P = .044), lower Po2/Fio2 and Po2 at the last blood gas analysis (66 vs 98 mm Hg, P = .032 and 39 vs 47 mm Hg, P = .008), and higher inotropic score (2 vs 0, P = .034). A multivariable logistic regression model showed that only inotropic score was significantly associated with reintubation ( P = .018).

Conclusions:

Immediate extubation in the operating room after pediatric cardiac surgery can be performed in most patients. Inotropic score is a predictor for reintubation in stage II palliation.

Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis

BACKGROUND

Hybrid coronary revascularization (HCR) combining minimally invasive grafting of the left internal mammary artery to the left anterior descending artery with percutaneous coronary intervention has become a viable option for treating coronary artery disease. The aim of this meta-analysis was to compare HCR with conventional coronary artery bypass grafting (CABG) in a range of clinical outcomes and hospital costs.

METHODS

To identify potential studies, systematic searches were carried out in various databases. The key search terms included "hybrid revascularization" AND "coronary artery bypass grafting" OR "HCR" OR "CABG." This was followed by a meta-analysis investigating the need for blood transfusion, hospital costs, ventilation time, hospital stay, cerebrovascular accident, myocardial infarction, mortality, postoperative atrial fibrillation, renal failure, operation duration, and ICU stay.

RESULTS

The requirement for blood transfusion was significantly lower for HCR: odds ratio 0.38 (95% confidence intervals [CIs] 0.31-0.46, P < .00001) as was the hospital stay: mean difference (MD) -1.48 days (95% CI, -2.61 to -0.36, P = 0.01) and the ventilation time: MD -8.99 hours (95% CI, -15.85 to -2.13, P = .01). On the contrary, hospital costs were more expensive for HCR: MD $3970 (95% CI, 2570-5370, P < .00001). All other comparisons were insignificant.

CONCLUSIONS

In the short-term, HCR is as safe as conventional CABG and may offer certain benefits such as a lower requirement for blood transfusion and shorter hospital stays. However, HCR is more expensive than conventional CABG.

The use of Rapid Shallow Breathing Index shortens time to extubation in patients undergoing coronary artery bypass grafting

Background

This study aims to investigate the effects of the use of the Rapid Shallow Breathing Index on extubation success and time to extubation in patients undergoing elective isolated coronary artery bypass grafting.

Methods

This prospective, randomized-controlled study included a total of 72 patients (55 males, 19 females; mean age 60.3±9.3 years; range 45 to 76 years) who underwent isolated coronary artery bypass grafting between February 2016 and November 2016. The patients were divided into two groups as the RSBI group (n=36) and the control group (n=36). The control group was extubated by conventional criteria that were routinely applied in our clinic, while the RSBI group was extubated, when the index scores became below 77 breaths per min/L, following ensuring hemodynamic stability and weaning procedure from mechanical ventilation.

Results

The mean time to wean from mechanical ventilation was 5.8±1.0 hours in the RSBI group and 8.1±2.0 hours in the control group (p=0.03). Extubation protocol performed through the use of the index was found to provide 26% earlier extubation compared to the conventional extubation criteria. There was no significant difference in the postoperative follow-up parameters or clinical conditions.

Conclusion

Our study results show that a practical tool such as the Rapid Shallow Breathing Index can be reliably used for making a decision in favor of extubation in patients undergoing coronary artery bypass grafting. A shortened time to extubation by the use of this index may provide substantial benefits in terms of prevention of infections, mechanical ventilation-induced lung injuries, and potential pulmonary complications.