Is Nocturnal Extubation After Cardiac Surgery Associated With Worse Outcomes?

Does Timing Matter? The Effect of Intensive Care Unit Arrival Timing on Elective Cardiac Surgery

BACKGROUND

Due to staffing changes at scheduled intervals and decreases in essential staff in the evenings, late intensive care unit (ICU) arrivals may be at risk for suboptimal outcomes. Utilizing a regional collaborative, we sought to determine the effect of ICU arrival timing on outcomes in elective isolated coronary artery bypass.

METHODS

Adults undergoing elective, isolated coronary artery bypass from 17 hospitals between 2013 and 2023 were identified. Patients with missing predicted risk of mortality or missing ICU arrival time were excluded. Late ICU arrival time was defined as between 6:00 pm and 6:00 am. Hierarchical logistic regression with appropriate predicted risk scores was utilized for outcome risk adjustment.

RESULTS

We identified 11,638 patients, with 972 (8.4%) experiencing late ICU arrival. Late ICU arrival patients had higher predicted risk of morbidity or mortality (8.2%; [interquartile range {IQR}, 5.6%, 12.0%] vs 7.7% [IQR, 5.5%, 11.5%], P = .048) compared with early ICU arrival patients with longer median cardiopulmonary bypass times (96 minutes [IQR, 78, 119] vs 93 [IQR, 73, 116], P < .001). Late ICU arrival patients experienced more unadjusted complications including prolonged ventilation (7.7% vs 4.2%, P < .001) and operative mortality (2.0% vs 1.1%, P = .02), although no difference in failure-to-rescue (11.0% vs 10.4%, P = .84). Logistic regression with risk adjustment demonstrated late ICU arrival as a predictor of prolonged ventilation (odds ratio, 1.49 [95% CI, 1.12-1.99], P = .006).

CONCLUSIONS

After adjustment, late ICU arrivals experienced higher rates of prolonged ventilation, although this did not translate to failure-to-rescue.

Association between night-time extubation and clinical outcomes in adult patients: A systematic review and meta-analysis

BACKGROUND

Whether night-time extubation is associated with clinical outcomes is unclear.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the association between night-time extubation and the reintubation rate, mortality, ICU and in-hospital length of stay in adult patients, compared with daytime extubation.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, CINAHL and Web of Science from inception to 2 January 2021 (PROSPERO registration - CRD42020222812).

ELIGIBILITY CRITERIA

Randomised, quasi and cluster randomised, and nonrandomised studies describing associations between adult patients' outcomes and time of extubation (daytime/night-time) in intensive care or postanaesthesia care units.

RESULTS

Seven retrospective studies were included in the systematic review and meta-analysis, for a total of 293 663 patients. All the studies were performed in United States (USA). All the studies were judged at moderate risk of bias for reintubation and mortality. The analyses were conducted with random effects models. The analyses from adjusted estimates demonstrated no association between night-time extubation and increased risk of either reintubation (OR 1.00; 95% CI 0.88 to 1.13; P = 1.00; I2 = 66%; low-certainty evidence) or all-cause mortality at the longest available follow-up (OR 1.11; 95% CI 0.87 to 1.42; P = 0.39; I2 = 79%; low-certainty evidence), in comparison with daytime extubation. Analyses from unadjusted data for reintubation, mortality and ICU or in-hospital length of stay showed no significant association with night-time extubation. Analyses based on type of admission, number of centres or duration of mechanical ventilation showed no significant subgroup effects.

CONCLUSION

Night-time extubation of adult patients was not associated with higher adjusted risks for reintubation or death, in comparison with daytime extubation, but the certainty of the evidence was low.

Factors Associated With Early Extubation After Cardiac Surgery: A Retrospective Single-Center Experience

OBJECTIVES

To identify factors associated with early extubation in cardiac surgery patients.

DESIGN

Single center, retrospective.

SETTING

Tertiary university hospital.

PARTICIPANTS

The study comprised 8,872 adult patients who underwent cardiothoracic surgery from 2011-2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 8,872 patients, 2,950 (33%) were extubated within six hours after surgery. Early extubated patients were younger, had a higher body mass index (BMI), were more likely to be male, and were fast-track designated. These patients more frequently underwent isolated coronary artery bypass graft, isolated valve, or adult congenital surgeries than did late extubated patients. Early extubated patients had a greater incidence of coronary artery disease (CAD) and anxiety and a higher left ventricular ejection fraction. They also were less likely to have difficult intubation or require mechanical circulatory support, reintubation, or readmission. Analysis of the 8,872 patients showed that male sex (odds ratio [OR] 1.222, 95% confidence interval [CI] 1.096-1.363), a BMI >30 kg/m² (OR 1.702, 95% CI 1.475-1.965), undergoing isolated valve surgery (OR 1.187, 95% CI 1.060-1.328), and having a fast-track designation (OR 1.455, 95% CI 1.208-1.751) and CAD (OR 1.122, 95% CI 1.005-1.253) were associated with early extubation. Data on intensive care unit (ICU) admission after surgery were available only from 2014-2018. Within this subgroup of 5,977 patients, variables associated with early extubation included male sex (OR 1.356, 95% CI 1.193-1.541), BMI >30 kg/m² (OR 1.267, 95% CI 1.084-1.480), daytime admission to the ICU (OR 1.712, 95% CI 1.527-1.919), and fast-track designation (OR 1.423, 95% CI 1.123-1.802).

CONCLUSIONS

Male sex; a BMI >30 kg/m²; undergoing isolated valve surgery; and having a fast-track designation, CAD, and daytime admission to the ICU are associated with early extubation.

Association of Overnight Extubation With Outcomes After Cardiac Surgery in the Intensive Care Unit

BACKGROUND

The frequency and safety of overnight extubation (OE) after cardiac surgery across intensive care units (ICUs) is unknown.

METHODS

We performed a retrospective study of adults (≥ 18 years) in US ICUs after coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both, using The Society of Thoracic Surgery Adult Cardiac Surgery Database (July 2014 to June 2017); our primary cohort was elective CABGs. We assessed OE (7:00 pm to 6:59 am) frequency and used multilevel regression modelling to identify factors associated with OE. Within mechanical ventilation (MV) duration strata, we used propensity score matching to evaluate associations of OE with reintubations (primary outcome), mortality, and complications.

RESULTS

Among 142,225 patients with elective CABG, 42.2% had OEs. MV duration, cardiopulmonary bypass time, distal anastomosis number, and hospital of admission (median odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.76 to 1.89) were independently associated with OE. After propensity matching, OE was associated with increased reintubation for patients with MV duration of 6 to 8 hours (2.2% vs 1.7%, OR 1.27, 95% CI: 1.04 to 1.56) and decreased reintubation for patients with MV duration of 15 to 17 hours (3.0% vs 4.2%, OR 0.70, 95% CI: 0.50 to 0.97) and 18 to 20 hours (2.3% vs 5.7%, OR 0.39, 95% CI: 0.21 to 0.72); OE was associated with increased ICU length of stay for patients with MV duration of 6 to 8 hours, but reduced length of stay for patients with MV duration of 9 to 20 hours. OE was not associated with increased mortality (hospital, 30-day). Other groups had similar OE rates (nonelective CABGs, 47.6%; elective AVR, 36.0%; elective CABG + AVRs, 51.0%) and outcomes.

CONCLUSIONS

OE is prevalent after cardiac surgery. OE is associated with little risk and reduces ICU length of stay for patients who require MV for more than 8 hours.