Optimizing timing of early extubation in coronary artery bypass surgery patients

Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND

Research on fast-track recovery protocols postulates that thoracic epidural anesthesia (TEA) in cardiac surgery contributes to improved postoperative outcomes. However, concerns about TEA's safety hinder its widespread usage. We conducted a systematic review and meta-analysis to assess the benefits and risks of TEA in cardiac surgery.

METHODS

We searched 4 databases for randomized controlled trials (RCTs) assessing the use of TEA against only general anesthesia (GA) in adults undergoing cardiac surgery, up till June 4, 2022. We conducted random-effects meta-analyses, evaluated risk of bias using the Cochrane Risk-of-Bias 2 tool, and rated certainty of evidence via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Primary outcomes were intensive care unit (ICU), hospital length of stay, extubation time (ET), and mortality. Other outcomes included postoperative complications. Trial sequential analysis (TSA) was conducted on all outcomes to elicit statistical and clinical benefit.

RESULTS

Our meta-analysis included 51 RCTs (2112 TEA patients and 2220 GA patients). TEA significantly reduced ICU length of stay (-6.9 hours; 95% confidence interval [CI], -12.5 to -1.2; P = .018), hospital length of stay (-0.8 days; 95% CI, -1.1 to -0.4; P < .0001), and ET (-2.9 hours; 95% CI, -3.7 to -2.0; P < .0001). However, we found no significant change in mortality. TSA found that the cumulative Z-curve passed the TSA-adjusted boundary for ICU length of stay, hospital length of stay, and ET, suggesting a clinical benefit. TEA also significantly reduced pain scores, pooled pulmonary complications, transfusion requirements, delirium, and arrhythmia, without additional complications such as epidural hematomas, of which the risk was estimated to be <0.14%.

CONCLUSIONS

TEA reduces ICU and hospital length of stay, and postoperative complications in patients undergoing cardiac surgery with minimal reported complications such as epidural hematomas. These findings favor the use of TEA in cardiac surgery and warrant consideration for use in cardiac surgeries worldwide.

Feasibility of Postoperative Day One or Day Two Discharge After Robotic Cardiac Surgery

INTRODUCTION

The robotic platform reduces the invasiveness of cardiac surgical procedures, thus facilitating earlier discharge in select patients. We sought to evaluate the characteristics, perioperative management, and early outcomes of patients who underwent postoperative day 1 or 2 (POD1-2) discharge after robotic cardiac surgery at our institution.

METHODS

Retrospective review of 169 patients who underwent robotic cardiac surgery at our facility between 2019 and 2021 identified 57 patients discharged early on POD1 (n = 19) or POD2 (n = 38) and 112 patients who underwent standard discharge (POD3 or later). Relevant data were extracted and compared.

RESULTS

In the early discharge group, median patient age was 62 [IQR: 55, 66] (IQR = interquartile range) years, and 70.2% (40/57) were male. Median Society of Thoracic Surgeons predictive risk of mortality score was 0.36 [IQR: 0.25, 0.56] %. The most common procedures performed were mitral valve repair [66.6%, (38/57)], atrial mass resection [10.5% (6/57)], and coronary artery bypass grafting [10.5% (6/57)]. The only significant differences between the POD1 and POD2 groups were shorter operative time, higher rate of in-operating room extubation, and shorter ICU length of stay in the POD1 group. Lower in-hospital morbidity and comparable 30-day mortality and readmission rates were observed between the early and standard discharge groups.

CONCLUSIONS

POD1-2 discharge after various robotic cardiac operations afforded lower morbidity and similar 30-day readmission and mortality rates compared to discharge on POD3 or later. Our findings support the feasibility of POD1-2 discharge after robotic cardiac surgery for patients with low preoperative risk, an uncomplicated postoperative course, and appropriate postoperative management protocols.

Effect of pecto-intercostal fascial block on extubation time in patients undergoing cardiac surgery: A randomized controlled trial

Objectives

Epidural and paravertebral block reduce the extubation time in patients undergoing surgery under general anesthesia but are relatively contraindicated in heparinized patients due to the potential risk of hematoma. The Pecto-intercostal fascial block (PIFB) is an alternative in such patients.

Methods

This is a single-center randomized controlled trial. Patients scheduled for elective open cardiac surgery were randomized at a 1:1 ratio to receive PIFB (30 ml 0.3% ropivacaine plus 2.5 mg dexamethasone on each side) or saline (30 ml normal saline on each side) after induction of general anesthesia. The primary outcome was extubation time after surgery. Secondary outcomes included opioid consumption during surgery, postoperative pain scores, adverse events related to opioids, and length of stay in the hospital.

Results

A total of 50 patients (mean age: 61.8 years; 34 men) were randomized (25 in each group). The surgeries included sole coronary artery bypass grafting in 38 patients, sole valve surgery in three patients, and both procedures in the remaining nine patients. Cardiopulmonary bypass was used in 20 (40%) patients. The time to extubation was 9.4 ± 4.1 h in the PIFB group vs. 12.1 ± 4.6 h in the control group (p = 0.031). Opioid (sufentanil) consumption during surgery was 153.2 ± 48.3 and 199.4 ± 51.7 μg, respectively (p = 0.002). In comparison to the control group, the PIFB group had a lower pain score while coughing (1.45 ± 1.43 vs. 3.00 ± 1.71, p = 0.021) and a similar pain score at rest at 12 h after surgery. The two groups did not differ in the rate of adverse events.

Conclusions

PIFB decreased the time to extubation in patients undergoing cardiac surgery.

Trial Registration

This trial is registered at the Chinese Clinical Trial Registry (ChiCTR2100052743) on November 4, 2021.

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.

Sonographically Measured Improvement in Diaphragmatic Mobility and Outcomes Among Patients Requiring Prolonged Weaning from the Ventilator

Background:

The need of prolonged weaning from the ventilator is a well-known predictor of an unfavorable patients` outcome. Diaphragmatic dysfunction is a serious problem for these patients. We wanted to determine the survival in patients who were already intubated for more than 4 weeks before they were admitted to our weaning unit. In this prospective study, we wanted to investigate if the diaphragmatic function could improve or was related to survival over an 18 months follow up period.

Methods:

84 patients were included when they were able to breathe at least 10 minutes over a t-piece and sit upright for at least 5 minutes. The diaphragmatic function was estimated sonographically using the up and downward movement of the lung silhouette. Sonographic follow-ups were performed for over 18 months. The survival rate, outcome and changes in diaphragm mobility were investigated.

Results:

a) Survival: 49 patients (58%) survived the 18 months follow up period - 30 had a good outcome; 19 needed assistance. b) Survival in relation to diaphragm mobility: If diaphragmatic mobility improved ≥ 15.5 mm on the left side, the probability of survival was 94% with a probability of 76% to have a satisfying outcome.

Conclusion:

Survival and outcome of prolonged weaning were significantly better when sonographically measured the mobility of left hemidiaphragm improved.

Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes

OBJECTIVE

To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes.

METHODS

This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death.

RESULTS

For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038).

CONCLUSION

Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.

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.

Establishing the Content Validity of an Early Extubation Protocol: A Quality Improvement Project for Improving Early Extubation of Coronary Artery Bypass Graft Patients

Introduction: Patients undergoing coronary artery bypass graft surgery will require intubation and the use of mechanical ventilation during and after surgery. It is well accepted that early extubation is associated with not only positive patient outcomes but also organizational outcomes as well. Patients who are not extubated early are at risk for complications associated with prolonged intubation. The literature supports the use of protocol aid with early extubation. The goal and expected outcome of this project is to establish the usability of an early extubation protocol by assessing its appropriateness for use in the postoperative cardiac surgical adult patient. Methods: For the purpose of establishing content validity of an early extubation protocol, 2 protocols were chosen from the literature. Fifteen cardiac surgery experts were invited to select the protocol they felt was most appropriate for use in this patient population. These reviewers were then asked to further analyze the protocol based on a 5-question survey. Their response was used to calculate a scale-content validity index (S-CVI) and an item-content validity index (I-CVI). Results: Twelve of 15 experts participated in the project. The content validity was estimated using (a) interrater agreement for relevance for each item (I-CVI) and (b) S-CVI. The means were established for each item. Content validity was estimated using (a) interrater agreement for relevance for each item (I-CVI: 0.75-1.00); and the S-CVI/average = 0.92. Cronbach's alpha was estimated to establish reliability (0.972). Conclusion: Selecting an appropriate protocol to be used in this patient population is the first step in implementing an effective early extubation process. The results highly suggest that the content of this protocol is quite relevant in this patient population. It is hoped that this will set the stage for early extubation in postoperative cardiac surgery patients.

Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: a comparison between artificial neural networks and logistic regression models

INTRODUCTION

In coronary artery bypass (CABG) surgery, the common complications are the need for reintubation, prolonged mechanical ventilation (PMV) and death. Thus, a reliable model for the prognostic evaluation of those particular outcomes is a worthwhile pursuit. The existence of such a system would lead to better resource planning, cost reductions and an increased ability to guide preventive strategies. The aim of this study was to compare different methods - logistic regression (LR) and artificial neural networks (ANNs) - in accomplishing this goal.

MATERIAL AND METHODS

Subjects undergoing CABG (n = 1315) were divided into training (n = 1053) and validation (n = 262) groups. The set of independent variables consisted of age, gender, weight, height, body mass index, diabetes, creatinine level, cardiopulmonary bypass, presence of preserved ventricular function, moderate and severe ventricular dysfunction and total number of grafts. The PMV was also an input for the prediction of death. The ability of ANN to discriminate outcomes was assessed using receiver-operating characteristic (ROC) analysis and the results were compared using a multivariate LR.

RESULTS

The ROC curve areas for LR and ANN models, respectively, were: for reintubation 0.62 (CI: 0.50-0.75) and 0.65 (CI: 0.53-0.77); for PMV 0.67 (CI: 0.57-0.78) and 0.72 (CI: 0.64-0.81); and for death 0.86 (CI: 0.79-0.93) and 0.85 (CI: 0.80-0.91). No differences were observed between models.

CONCLUSIONS

The ANN has similar discriminating power in predicting reintubation, PMV and death outcomes. Thus, both models may be applicable as a predictor for these outcomes in subjects undergoing CABG.

Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.

Predictors of prolonged mechanical ventilation after open heart surgery

Introduction: Due to the importance of prolonged mechanical ventilation (PMV) as a postoperative complication, predicting "high-risk" patients by identifying predisposing risk factors is of important issue. The present study was aimed to identify perioperative variables associated with PMV in patients undergoing open heart surgery.

Methods: A total of 743 consecutive patients, American Society of Anesthesiologists (ASA) physical status class III, who were scheduled to undergo open heart surgery using cardiopulmonary bypass were included in this observational study. Perioperative variables were compared between the patients with and without PMV, as defined by an extubation time of >48 h.

Results: PMV occurred in 45 (6.1%) patients. On univariate analysis, pre-operative variables; including gender, history of chronic obstructive pulmonary disease (COPD); chronic kidney disease and endocarditis, intra-operative variables; including type of surgery, operation time, pump time, transfusion in operating room and postoperative variables; including bleeding and inotrope-dependency were significantly different between patients with and without PMV (all P<0.001, except for COPD and transfusion in operating room; P=0.004 and P=0.017, respectively).

Conclusion: Our findings reinforce that risk stratification for predicting delayed extubation should be an important aspect of preoperative clinical evaluation in all anesthesiology settings.

Daytime Versus Nighttime Extubations

Purpose:

Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time.

Methods:

A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm.

Results:

Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night ( P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night.

Conclusions:

Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

Risk factor analysis for fast track protocol failure

BACKGROUND

The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.

METHODS

229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.

RESULTS

Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).

CONCLUSION

Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.

Risk model of prolonged intensive care unit stay in Chinese patients undergoing heart valve surgery

BACKGROUND

The aim of this study was to develop a preoperative risk prediction model and an scorecard for prolonged intensive care unit length of stay (PrlICULOS) in adult patients undergoing heart valve surgery.

METHODS

This is a retrospective observational study of collected data on 3925 consecutive patients older than 18 years, who had undergone heart valve surgery between January 2000 and December 2010. Data were randomly split into a development dataset (n=2401) and a validation dataset (n=1524). A multivariate logistic regression analysis was undertaken using the development dataset to identify independent risk factors for PrlICULOS. Performance of the model was then assessed by observed and expected rates of PrlICULOS on the development and validation dataset. Model calibration and discriminatory ability were analysed by the Hosmer-Lemeshow goodness-of-fit statistic and the area under the receiver operating characteristic (ROC) curve, respectively.

RESULTS

There were 491 patients that required PrlICULOS (12.5%). Preoperative independent predictors of PrlICULOS are shown with odds ratio as follows: (1) age, 1.4; (2) chronic obstructive pulmonary disease (COPD), 1.8; (3) atrial fibrillation, 1.4; (4) left bundle branch block, 2.7; (5) ejection fraction, 1.4; (6) left ventricle weight, 1.5; (7) New York Heart Association class III-IV, 1.8; (8) critical preoperative state, 2.0; (9) perivalvular leakage, 6.4; (10) tricuspid valve replacement, 3.8; (11) concurrent CABG, 2.8; and (12) concurrent other cardiac surgery, 1.8. The Hosmer-Lemeshow goodness-of-fit statistic was not statistically significant in both development and validation dataset (P=0.365 vs P=0.310). The ROC curve for the prediction of PrlICULOS in development and validation dataset was 0.717 and 0.700, respectively.

CONCLUSION

We developed and validated a local risk prediction model for PrlICULOS after adult heart valve surgery. This model can be used to calculate patient-specific risk with an equivalent predicted risk at our centre in future clinical practice.

Predictors of successful early extubation following congenital cardiac surgery in neonates and infants

BACKGROUND

There is a paucity of literature discussing the predictive likelihood of successfully extubating neonates and infants in the operating room immediately following congenital cardiac surgery. Given the unknown consequences of anaesthetics on neurodevelopmental outcomes, minimising the exposure of this population to such agents may have long-term benefits.

METHODS

Retrospective chart review of 391 patients less than 1 year of age.

RESULTS

The probability of successfully extubating these patients was based on quantifiable, objective criteria. The relevant variables include age, weight, bypass time, lactate level and specific congenital anomaly.

CONCLUSIONS

The practice of immediate extubation of infants and neonates is achievable, safe and predicted based on specific patient variables. This practice will minimise the anaesthetic exposure of these especially young patients who may be at risk for long-term consequences related to anaesthetic exposure.

The changing epidemiology of mechanical ventilation: a population-based study

The number of critical care beds in the United States has been increasing considerably, but it is unclear how these additional beds have been used. Mechanical ventilation for acute respiratory failure almost always demands ICU care and is likely to be a reliable indicator of critical care resource requirements on a population level. The objective of this study was to measure changes in the yearly incidence of mechanical ventilation in a statewide population. The North Carolina Hospital Discharge Database contains data on all discharges from nonfederal, nonpsychiatric hospitals in North Carolina. Authors extracted data on adult patients with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for mechanical ventilation from 1996 to 2002. The incidence of mechanical ventilation for adults grew from 284/100,000 population in 1996 to 314/100,000 in 2002, an increase of 11% (P < .05). While patients aged >64 had the highest age-specific incidence of mechanical ventilation each year, the greatest increase in incidence occurred in younger age groups (19% increase for age 18-64 vs 4% increase for age >64). The mean Charlson score increased from 1.76 +/- 1.73 to 1.89 +/- 1.86 (P < .001). Renal disease became more prevalent among patients requiring mechanical ventilation (17% of patients in 1996 vs 24% in 2002). Hospital charges adjusted for the medical consumer price index increased by 12%. The proportion of patients discharged to home declined from 45.4% to 34.4%, and discharges to nursing homes grew from 7.3% to 10.7%. The incidence of mechanical ventilation is increasing, and the increase is associated with a higher burden of comorbidities and fewer discharges to home.

Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials*

OBJECTIVE

Evaluation of randomized, controlled clinical trials studying fast-track treatment in low-risk coronary artery bypass grafting patients.

DESIGN

Meta-regression.

PATIENTS

Low-risk coronary artery bypass grafting patients.

INTERVENTIONS

Fast-track treatments including (high or low) anesthetic dose, normothermia vs. hypothermia, and extubation protocol (within or after 8 hrs).

MEASUREMENTS

Number of hours of intensive care unit stay, number of days of hospital stay, prevalence of myocardial infarction, and death. Furthermore, quality of life and cost evaluations were evaluated. The epidemiologic and economic qualities of the different trials were also assessed.

MAIN RESULTS

A total of 27 studies evaluating fast-track treatment were identified, of which 12 studies were with major and 15 were without major differences in extubation protocol or anesthetic treatment or both. The use of an early extubation protocol (p=.000) but not the use of a low anesthetic dose (p=.394) or normothermic temperature management (p=.552) resulted in a decrease of the total intensive care unit stay of low-risk coronary artery bypass grafting patients. Early extubation was found to be an important determinant of the total hospital stay for these patients. An influence of the type of fast-track treatment on mortality or the prevalence of postoperative myocardial infarction was not observed. In general, the epidemiologic and economic qualities of included studies were moderate.

CONCLUSIONS

Although fast-track anesthetics and normothermic temperature management facilitate early extubation, the introduction of an early extubation protocol seems essential to decrease intensive care unit and hospital stay in low-risk coronary artery bypass grafting patients.

Outcomes of early extubation after bypass surgery in the elderly

BACKGROUND

While early extubation after coronary artery bypass grafting (CABG) has been associated with resource savings, its effect on patient outcomes remains unclear. The goal of the present investigation was to evaluate whether early extubation can be performed safely in elderly CABG patients in community practice.

METHODS

We studied 6,446 CABG patients, aged 65 years and older, treated at 35 hospitals between 1995 and 1998. Patients were categorized based on their post-CABG extubation duration (early, < 6 hours; intermediate, 6 to < 12 hours; and late, 12 to 24 hours). We compared unadjusted and risk-adjusted mortality, reintubation rates, and post-CABG length of stay (pLOS). We also examined the association between patients' intubation time and outcomes among patients with similar propensity for early extubation and among high-risk patient subgroups.

RESULTS

The overall mean post-CABG intubation time was 9.8 (SD 5.7) hours with 29% of patients extubated within 6 hours. After adjusting for preoperative risk factors patients extubated in less than 6 hours had significantly shorter postoperative hospital stays than those with later extubation times. Patients extubated early also tended to have equal or better risk-adjusted mortality than those with intermediate (odds ratio: 1.69, p = 0.08) or long intubation times (odds ratio: 1.97, p = 0.02). These results were consistent among patients with similar preoperative propensity for early extubation and among important high-risk patient subgroups. There was no evidence for higher reintubation rates among elderly patients selected for early extubation.

CONCLUSIONS

In community practice, early extubation after CABG can be achieved safely in selected elderly patients. This practice was associated with shorter hospital stays without adverse impact on postoperative outcomes.

[High thoracic epidural anesthesia in coronary surgery]

INTRODUCTION

High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympthatetic blockade.

EFFECTS OF HIGH THORACIC EPIDURAL ANESTHESIA

Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity.

RESULTS OF CLINICAL STUDIES

Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress.

HIGH THORACIC EPIDURAL ANESTHESIA TECHNIQUE

The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended.

CONCLUSION

There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.

Do intraoperative variables have an effect on the timing of tracheal extubation after coronary artery bypass graft surgery?

OBJECTIVE

The purpose of this study was to investigate whether any intraoperative variable had a significant effect on extubation time after coronary artery bypass graft surgery.

DESIGN

Study design was a retrospective study.

SETTING

Study took place in 1 cardiac center in the United Kingdom that had 1000 cases per year.

SUBJECTS

Eighty-nine patients had coronary artery bypass graft surgery in the first 6 months of 1998 performed by one consultant cardiac surgeon.

OUTCOME MEASURES

Study measures included intraoperative variables (number of vessels grafted, time on cardiopulmonary bypass [CPB], length of the operation, use of internal mammary artery) and extubation time.

RESULTS

Mean extubation time was 4.97 hours. On analysis via linear regression no intraoperative variables were found to be statistically significant (P = .05) to extubation time.

CONCLUSION

This study identified that early extubation can be achieved safely. Although no variable was found to have a significant effect on extubation time, the relationship between CPB and extubation may have been attributed to the low mean CPB time within the study (49.1 minutes). The relationship between cardiac status, ischemia, and the timing of extubation does warrant additional exploration.