Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial

Operating Room Extubation for Patients Undergoing Cardiac Surgery: A National Society of Thoracic Surgeons Database Analysis

BACKGROUND

The utility of operating room extubation (ORE) after cardiac surgery over fast-track extubation (FTE) within 6 hours remains contested. We hypothesized ORE would be associated with equivalent rates of morbidity and mortality, relative to FTE.

METHODS

Patients undergoing nonemergent cardiac surgery were identified in The Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2017 and December 2022. Only procedures with The Society of Thoracic Surgeons risk models were included. Risk-adjusted outcomes of ORE and FTE were compared by observed-to-expected ratios with 95% CIs aggregated over all procedure types, and ORE vs FTE adjusted odds ratios (ORs) specific to each procedure type using multivariable logistic regression. Analyzed outcomes were operative mortality, prolonged length of stay, composite reoperation for bleeding and reintubation, and composite morbidity and mortality.

RESULTS

The study population of 669,099 patients across 1069 hospitals included 36,298 ORE patients in 296 hospitals. Risk-adjusted analyses found that ORE was associated with statistically similar or better results across each of the 4 outcomes and procedure subtypes. Notably, rates of postoperative mortality were significantly lower in ORE patients undergoing coronary artery bypass grafting (OR, 0.54; 95% CI, 0.46-0.65), aortic valve replacement (OR, 0.43; 95% CI, 0.24-0.77), and mitral valve replacement (OR, 0.48; 95% CI, 0.26-0.89).

CONCLUSIONS

Extubation in the OR was safe and effective in a selected patient population and may be associated with superior outcomes in coronary artery bypass, aortic valve replacement, and mitral valve replacement. These national data appear to confirm institutional experiences regarding the potential benefit of OR extubation. Further refinement of optimal populations may justify randomized investigation.

Routine Extubation in the Operating Room After Isolated Coronary Artery Bypass

BACKGROUND

The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG).

METHODS

The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared.

RESULTS

Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04).

CONCLUSIONS

Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.

On-table Extubation After Minimally Invasive Cardiac Surgery: A Retrospective Observational Pilot Study

OBJECTIVE

To assess the safety of "on-table" extubation after minimally-invasive heart valve surgery.

DESIGN

A single-center retrospective observational study.

SETTING

At a tertiary referral academic hospital.

PARTICIPANTS

Patients who underwent nonemergent isolated heart valve surgery through a minithoracotomy approach between January 2016 and August 2021.

INTERVENTION

All patients were treated by 1 of the 6 cardiac anesthesiologists of the hospital. Only some of them practiced "on-table" extubation, and the outcome of patients extubated "on-table" was compared to those extubated in the intensive care unit (ICU).

MEASUREMENT AND MAIN RESULTS

The primary outcome was the occurrence of any postoperative respiratory complication during the entire hospital stay. Secondary outcomes included the use of inotropes and vasopressors, de novo atrial fibrillation, and lengths of stay in the ICU and the hospital. A total of 294 patients met inclusion criteria, of whom 186 (63%) were extubated "on-table." Cardiopulmonary bypass duration was significantly longer, and moderate intraoperative hypothermia was significantly more frequent in patients extubated in the ICU. After adjustment for these confounders and for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II using a multivariate logistic model, no association was found between the extubation strategy and postoperative pulmonary complications (adjusted odds ratio = 0.84; 95% CI = 0.40-1.77; p = 0.64). "On-table" extubation was associated with a lower risk of postoperative pneumonia and fewer vasopressors requirements.

CONCLUSION

"On-table" extubation was not associated with an increased incidence of respiratory complications. A randomized controlled trial is warranted to confirm these results and determine whether "on-table" extubation offers additional benefits.

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.

Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study

AIM OF THIS STUDY

This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes.

MATERIALS AND METHODS

We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation.

RESULTS

52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation.

CONCLUSIONS

We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.

What Is Known about Midazolam? A Bibliometric Approach of the Literature

Midazolam is a drug with actions towards the central nervous system producing sedative and anticonvulsants effects, used for sedation and seizures treatments. A better understanding about its effects in the different scenarios presented in the literature could be helpful to gather information regarding its clinical indications, pharmacological interactions, and adverse events. From this perspective, the aim of this study was to analyze the global research about midazolam mapping, specifically the knowledge of the 100 most-cited papers about this research field. For this, a search was executed on the Web of Science-Core Collection database using bibliometric methodological tools. The search strategy retrieved 34,799 articles. A total of 170 articles were evaluated, with 70 articles being excluded for not meeting the inclusion criteria. The 100 most-cited articles rendered 42,480 citations on WoS-CC, ranging from 253 to 1744. Non-systematic review was the most published study type, mainly from North America, during the period of 1992 to 2002. The most frequent keywords were midazolam and pharmacokinetics. Regarding the authors, Thummel and Kunze were the ones with the greatest number of papers included. Our findings showed the global research trends about midazolam, mainly related to its different effects and uses throughout the time.

Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs

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.

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.

Capnography and Pulse Oximetry Improve Fast Track Extubation in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial

Background

Use of capnography as a non-invasive method during the weaning process for fast track extubation (FTE) is controversial. We conducted the present study to determine whether pulse oximetry and capnography could be utilized as alternatives to arterial blood gas (ABG) measurements in patients under mechanical ventilation (MV) following coronary artery bypass graft (CABG) surgery.

Methods

In this randomized clinical trial, 70 patients, who were candidates for CABG surgery, were randomly assigned into two equal groups (n = 35), intervention and control group. In the intervention group, the ventilator management and weaning from MV was done using Etco2 from capnography and SpO2 from pulse oximetry. Meanwhile, in the control group, weaning was done based on ABG analysis. The length of intensive care unit (ICU) stay, time to extubation, number of manual ventilators setting changes, and alarms were compared between the groups.

Results

The end-tidal carbon dioxide (ETCO2) levels in the intervention group were completely similar to the partial pressure of carbon dioxide (PaCo2) in the control group (39.5 ± 3.1 vs. 39.4 ± 4.32, p > 0.05). The mean extubation times were significantly shorter in the intervention group compared to those in the control patients (212.2 ± 80.6 vs. 342.7 ± 110.7, p < 0.001). Moreover, the number of changes in the manual ventilator setting and the number of alarms were significantly lower in the intervention group. However, the differences in the length of stay in ICU between the two groups were not significant (p = 0.219).

Conclusion

Our results suggests that capnography can be used as an alternative to ABG. Furthermore, it is a safe and valuable monitor that could be a good alternative for ABG in this population. Further studies with larger sample sizes and on different disease states and populations are required to assess the accuracy of our findings.

Clinical Trial Registration

Current Controlled Trials, IRCT, IRCT201701016778N6, Registered 3 March 2017, https://www.irct.ir/trial/7192.

Combining Minimally Invasive Surgery With Ultra-Fast-Track Anesthesia in HeartMate 3 Patients: A Pilot Study

BACKGROUND

Minimally invasive surgery for left ventricular assist device implantation may have advantages over conventional sternotomy (CS). Additionally, ultra-fast-track anesthesia has been linked to better outcomes after cardiac surgery. This study summarizes our early experience of combining minimally invasive surgery with ultra-fast-track anesthesia (MIFTA) in patients receiving HeartMate 3 devices and compares the outcomes between MIFTA and CS.

METHODS

From October 2015 to January 2019, 18 of 49 patients with Interagency Registry for Mechanically Assisted Circulatory Support profiles >1 underwent MIFTA for HeartMate 3 implantation. For bias reduction, propensity scores were calculated and used as a covariate in a regression model to analyze outcomes. Weighted parametric survival analysis was performed.

RESULTS

In the MIFTA group, intensive care unit stays were shorter (mean difference, 8 days [95% CI, 4-13]; P<0.001), and the incidences of pneumonia and right heart failure were lower than those in the CS group (odds ratio, 1.36 [95% CI, 1.01-1.75]; P=0.016, respectively). At 6 and 12 hours postoperatively, MIFTA patients had a better hemodynamic performance with lower pulmonary wedge pressure (mean difference, 2.23 mm Hg [95% CI, 0.41-4.06]; P=0.028) and a higher right ventricular stroke work index (mean difference, -1.49 g·m/m² per beat [95% CI, -2.95 to -0.02]; P=0.031). CS patients had a worse right heart failure-free survival rate (hazard ratio, 2.35 [95% CI, 0.96-5.72]; P<0.01).

CONCLUSIONS

Compared with CS, MIFTA is a beneficial approach for non-Interagency Registry for Mechanically Assisted Circulatory Support 1 HeartMate 3 patients with lower adverse event incidences, better hemodynamic performance, and preserved right heart function. Future large multicentric investigations are required to verify MIFTA's effects on outcomes.

ICU Nurses-An Impact Factor on Patient Turnover in Cardiac Surgery in Western Denmark?

OBJECTIVE

The aim of this study was to describe changes in performance indicators such as length of stay [LOS] in the intensive care unit [ICU] and ventilation time, during the last six years in an attempt to identify associations between patient and systemic performance indicators, including the impact of nurse turnover.

DESIGN

A retrospective study of prospectively registered data (2013-2018). Propensity- score matching was performed to establish comparable groups.

SETTING

Three Danish university hospitals.

PARTICIPANTS

The study included a total of 12,404 adult cardiac surgical patients registered in the Western Denmark Heart Registry. The cohort was divided into an "early" group (2013-2016) and a "late" group (2017-2018).

INTERVENTIONS

An analysis of dynamics in patient indicators and systemic performance indicators, including the impact from selected performance parameters and nurse turnover.

MEASUREMENTS AND MAIN RESULTS

Comorbidity, calculated from the European System for Cardiac Operative Risk Evaluation, and the mean age were stable in the study period. Strong predictors of long LOS in the ICU included postoperative use of inotropes, re-exploration surgery, high postoperative drainage, and the "late" time group. Time parameters (relative risks) were all significantly longer in the "late" time group": ventilation time 1.21 (1.05-1.39), length of stay ICU 1.28 (1.11-1.48), and in-hospital time 1.36 (1.19-1.57). ICU nurse turnover increased from four (2013-2014) to 52 (2017-2018).

CONCLUSION

No single patient factor, such as age or comorbidity, could explain the decrease in patient turnover in the ICU. In the same period, the turnover of ICU nurses increased. Patient turnover is complex and affected by a mix of patient and systemic performance factors.

Malewicz N, Ebel M, K. Zahn P, H. Meyer-Frießem C. Pupillometric Monitoring of Nociception in Cardiac Anesthesia

BACKGROUND

High-dose opioids are conventionally used for cardiac anesthesia, but without monitoring of nociception. In non-cardiac surgical procedures the intra - operative dose of opioids can be individualized and reduced with pupillometric monitoring of the pupillary pain index (PPI; scale 1-9). A randomized controlled trial was carried out to explore whether pupillometry can be used for nociception monitoring in cardiac anesthesia and whether it leads to opioid reduction.

METHODS

A sample of 57 cardiac surgery patients receiving continuously administered sufentanil (initial dosage 0.7 μg*kg-¹*h-¹) was divided into a PPI group (sufentanil reduction if PPI<3 up to a minimum of 0.15 μg*kg-¹*h-¹, n=32) and a control group (standard anesthesia; n = 25). The primary outcome was the time from the end of anesthesia to extubation. The secondary outcomes were total intraoperative dose of sufentanil/noradrenaline, postoperative pain intensity (numeric rating scale [NRS] 0-10) and intraoperative awareness. German Clinical Trials Registry no. DRKS 00012329.

RESULTS

The primary outcome, extubation time, did not differ between the two groups (1.14 h, 95% confidence interval [-0.99; 3.27], p = 0.592). Compared with the control patients (68% male, age 70 ± 10.4 years, PPI 1.1 ± 0.2), the mean sufentanil infusion rate in the PPI patients (81% male, age 68 ± 10.3 years, PPI 1.1 ± 0.2) decreased by 81.8% (-0.68 μg*kg-¹*h-¹ [-0,7; -0.67], p<0.001) to the predetermined minimum level, without intraoperative awareness. Moreover, the noradrenaline dose was reduced by 56% (1235.51 μg [321.91; 2149.12], p = 0.005) and the postoperative pain intensity by 45% (2.11 NRS [0.93; 3.3] after 24 h, p = 0.003).

CONCLUSION

Pupillometry is appropriate for nociception monitoring in cardiac anesthesia. Thereby a considerable reduction of intraoperative opioids as well as increased intraoperative hemodynamic stability was achieved and postoperative opioid-induced hyperalgesia was prevented. The consistently low PPI scores, indicating adequate analgesia, suggest that further reduction of opioid doses is feasible.

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.

Fast-track cardiac anaesthesia protocols: Is quality pushed to the edge?

Background

The quest for methods expediting rapid postoperative patient turnover has triggered implementation of various fast-track cardiac anaesthesia protocols. Using three different fast-track protocols in randomized controlled studies (RCT) conducted 2010-2016 we found minimal achievements in ventilation time together with actual and eligible length of stay in cardiac recovery unit. The comparable control group patients were evaluated in this retrospective post hoc analysis, for an association between above mentioned parameters and quality parameters, to assess whether the marginal gains have been at the expense of quality of recovery and patient comfort.

Method

90 control patients from three RCT with comparable demographic parameters and receiving standard department treatment were evaluated using time parameters and an objective/semi-objective Intensive Care Unit (ICU) score system (IDS score).

Results

Ventilation time was statistical significant lower in latest study (C) than the early (A) and intermedium (B) studies (A=293, B=261, C=205 minutes; P=0.04). The IDS was lower at extubation and all time points in the early study compared to other studies (P < 0.001;). The average IDS in latest study were the double of previous studies at the end of observations, and marginally above the acceptable score for discharge. The postoperative morphine requirement A=15.0, B=10.0 and C=26.5 mg; P=0.002) was statistical significant higher in the latest study compared to previous studies.

Conclusion

The implementation of strict fast-track protocols resulting in shorter ventilation time did not convert to earlier eligibility to discharge from the ICU. However, the quality of recovery appears challenged.

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study

BACKGROUND AND OBJECTIVES

Although high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery.

METHODS

Elective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days).

RESULTS

In the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084).

CONCLUSIONS

HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.

The Major Decrease in Resource Utilization in Recent Decades Seems Guided by Demographic Changes: Fast Tracking-Real Concept or Demographics

OBJECTIVE

To identify dynamics of associations and potential areas for optimization of patient turnover between various patient profile and comorbidity indicators and selected system performance indicators such as ventilation time, length of stay in the intensive care unit, and in-hospital stay.

DESIGN

Retrospective study of prospectively registered data (2000-2017).

SETTING

Three university hospitals.

PARTICIPANTS

The study comprised 38,100 adult cardiac surgical patients registered in the Western Denmark Heart Registry.

INTERVENTIONS

Analysis of dynamics in patient indicators and system performance indicators, including effect on the selected performance parameters.

MEASUREMENTS AND MAIN RESULTS

Comorbidity, calculated from EuroSCORE, decreased from 2.5 ± 2.2 to 1.5 ± 2.0 (p < 0.001), whereas the average age of patients increased from 65.1 ± 9.9 years to 67.6 ± 10.8 years (p < 0.001). Median ventilation time decreased from 380 to 275 minutes (p < 0.0001). The mean length of stay in the intensive care unit demonstrated a statistically significant decrease from 35.1 hours between 2000 to 2002 to 31.8 hours between 2015 to 2017 (p = 0.004), and the median time was unchanged at 22.0 hours throughout the observation period. The median in-hospital stay decreased from 6.5 to 5.1 days (p < 0.001) and the mean in-hospital stay from 8.7 days (2003-2005) to 7.0 days (2015-2017; p < 0.001). Logistic regression analysis of performance factors showed a statistically significant negative independent effect on most comorbidity and surgical factors.

CONCLUSION

The increase in performance parameters appears to be highly associated with decreased comorbidities and fast-tracking protocols and may only offer limited effect in additional patient turnover.

To extubate or not to extubate: Risk factors for extubation failure and deterioration with further mechanical ventilation

BACKGROUND

Extubation is a critical step in the intensive care unit (ICU). In this study, we aim to investigate the risk factors for both extubation failure and deterioration with further mechanical ventilation (MV).

METHODS

Data were collected from a cardiothoracic ICU in a tertiary hospital. The risk factors for extubation failure and deterioration with further MV were investigated by multivariate logistic regression.

RESULTS

A total of 676 patients were enrolled in the study. Patients with extubation failure had a longer ICU length of stay and a higher mortality rate than patients without extubation failure. An age greater than 65 years, abnormal heart rate, respiratory rate exceeding 20 times/min, arterial pH lower than 7.35, pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio lower than 300 mmHg, mean arterial pressure lower than 70 mmHg, duration of MV longer than 12 hours, and high quick Sequential Organ Failure Assessment (qSOFA) score were independent risk factors for extubation failure. Furthermore, we found that a respiratory rate greater than 20 times/min and a PaO2/fraction of Inspired Oxygen FiO2 ratio less than 300 mmHg were protective factors, while a mean arterial pressure lower than 70 mmHg, arterial pH lower than 7.35, and high qSOFA score were risk factors for deterioration on continued MV.

CONCLUSIONS

Since the duration of MV increases the risk of extubation failure, physicians should consider not only the risk of extubation failure but also the risk of deterioration with further MV.

Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

BACKGROUND

Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.

AIM

To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.

METHODS

A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared “standard practice” and “intervention” periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24^th postoperative hour.

RESULTS

Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12^th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12^th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).

CONCLUSION

The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

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.

Impact of Intubation Time on Survival following Coronary Artery Bypass Grafting: Insights from the Surgical Treatment for Ischemic Heart Failure (STICH) Trial

OBJECTIVE

The authors aimed to assess determinants of intubation time and evaluate its impact on 30-day and 1-year postoperative survival in Surgical Treatment for Ischemic Heart Failure (STICH) trial patients.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

A multivariable Cox proportional hazards model was used among the 1,446 surgical patients from the STICH trial who survived 36 hours after operation, in order to identify perioperative factors associated with 30-day and 1-year postoperative mortality. A multivariable logistic regression model was used to determine risk factors associated with intubation time.

MEASUREMENTS AND MAIN RESULTS

At 36 hours post-operation, 1,298 (out of 1,446) were extubated and 148 (10.2%) still intubated. Median postoperative intubation time was 11.4 hours. Among patients surviving 36 hours, a multivariable model was developed to predict 30-day (c-index = 0.88) and 1-year (c-index = 0.78) mortality. Intubation time was the strongest independent predictor of 30-day (hazard ratio [HR] 5.50) and 1-year mortality (HR 3.69). Predictors of intubation time >36 hours included mitral valve procedure, New York Heart Association class, left ventricular systolic volume index, creatinine, previous coronary artery bypass grafting (CABG), and age. Results were similar in patients surviving 24 hours post-operation, where intubation time was also the strongest predictor of 30-day (HR 4.18, c-index 0.87) and 1-year (HR 2.81, c-index 0.78) mortality.

CONCLUSIONS

Intubation time is the strongest predictor of 30-day and 1-year mortality among patients with ischemic heart failure undergoing CABG. Combining intubation time with other mortality risk factors may allow the identification of patients at the highest risk for whom the development of specific strategies may improve outcomes.

Factors affecting reintubations after cardiac and thoracic surgeries in cardiac intensive care unit of a tertiary care hospital

Background

Reintubation and readmission after cardiothoracic surgeries are not uncommon, and its reasons are multifactorial. The study goal was to identify the factors that contribute reintubation after cardiac and thoracic surgery in tertiary care hospital and to compare the outcome with international benchmark.

Methodology

A prospective, observational study was planned in Cardiac Intensive Care Unit (CICU). The study included all those patients who required readmission in CICU due to endotracheal intubation following cardiac and thoracic surgeries. The study was conducted from January to December 2016. The primary focus was to identify the reasons for reintubation within 72 h of extubation after CICU discharge and its association with outcome.

Results

Out of 750 patients who shifted out from CICU following successful extubation, only 32 were readmitted and among them in 25 patients (3.33%) were reintubated and their reasons reintubation were noted. Patients underwent a coronary artery bypass grafting (CABG) with valve replacement had a higher incidence of reintubation 3/39 (7.69%) when compared with CABG 13/517 (2.51%) and 4/135 (2.96%) valve procedure alone. Single cause of endotracheal reintubation was observed in 7 patients (28%), in which 5 patients (20%) had respiratory and 2 patients had (8%) cardiac reason while 18 patients (72%) were observed with multisystem involvement, in which 7 patients (28%) had both respiratory and cardiovascular causes, and 2 (8%) had both respiratory and neurological causes. More than 70% cause of endotracheal reintubation was both respiratory and cardiovascular. The CICU stay after reintubations was 12.88 ± 16.88 days and the hospital stay prolonged to 23.84 ± 21.61 days.

Conclusion

Reasons of reintubation were mainly respiratory and cardiac. The rate of reintubations is high when multisystem involvement is there. CICU, hospital stay, and mortality are increases after reintubation.

[Implication of early extubation after cardiac surgery for postoperative rehabilitation]

Introduction

Postoperative rehabilitation after cardiac surgery is based on medical-surgical management in order to reduce the lenght of stay in hospital and the costs of this high risk surgery. Early tracheal extubation (within the first 6 hours) is the cornerstone of fast-track surgery. Our study aimed to evaluate fast-track practice and early tracheal extubation in scheduled cardiac surgery for adult patients in our Institution.

Methods

We conducted a descriptive study including all patients aged over 18 years who consecutively had undergone scheduled cardiac surgery and postoperative treatment in the post-operative intensive care unit in the Department of Thoracic and Cardiovascular Surgery at the Habib Bourguiba University Hospital, Sfax. Inclusion criteria were: patients aged 18 years and older who had undergone scheduled cardiac surgery and postoperative treatment in the post-operative intensive care unit in the Department of Thoracic and Cardiovascular Surgery. Standardized anaesthetic protocol was used in all cases: propofol, remifentanil, cisatracrium. We recorded the mean postoperative extubation time and the factors affecting extubation time.

Results

We collected data from 200 patients who consecutively had undergone scheduled cardiac surgery. Among these patients, 115 underwent coronary artery bypass surgery, 79 valvular surgery and 6 combined surgery or another surgical procedure. Patients' demographic characteristics were comparable. 152 patients (76%) underwent postoperative extubation within the first 6 hours. 48 patients couldn't be extubated within the FIrst 6 hours. The main causes of early extubation failure were: catecholamines in high doses, bleeding, arrhythmia and neurological disorders.

Conclusion

Our study demonstrates that postoperative rehabilitation can be performed in our Institution and that all patients undergoing scheduled cardiac surgery should be candidates for early extubation.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

Objective

Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward.

Methods

In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics.

Results

Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days.

Conclusions

In patients undergoing robotic-assisted CABG, ultrafasttrack cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Lower Dose of Sufentanil Does Not Enhance Fast Track Significantly-A Randomized Study

OBJECTIVE

Adjustment in the doses of opioids has been a focus of interest for achieving better fast-track conditions in cardiac anesthesia, but relatively sparse information exists on the potential effect of psychologic and behavioral factors, such as stress, anxiety, and type of personality, on anesthesia requirements and patient turnover in the cardiac recovery unit (CRU); to the authors' knowledge, this particular focus has not been systematically investigated. In this randomized study, the authors tested the hypothesis that low-dose sufentanil, compared with a standard dose, can improve fast-track parameters and the overall quality of recovery. Opioid requirements related to personality type, pain sensitivity, and preoperative stress and anxiety also were assessed.

DESIGN

A randomized, prospective study.

PARTICIPANTS

The study comprised 60 patients scheduled for elective coronary artery bypass grafting with or without aortic valve replacement.

SETTING

A university hospital.

INTERVENTIONS

Patients were randomly assigned to receive either a standard dose (bolus 0.5 µg/kg) or low dose (bolus 0.25 µg/kg) of sufentanil combined with propofol.

MEASUREMENTS AND MAIN RESULTS

The primary outcome variables were ventilation time and eligible time to discharge from the CRU. The secondary objective was to evaluate the relationship between opioid requirements and personality type, pain sensitivity, and preoperative stress and anxiety. The groups were comparable in selected demographics and perioperative parameters. There was no difference between groups in ventilation time (low dose: 191 [163-257] v standard dose: 205 [139-279] min; p = 0.405); eligible CRU discharge time (10.3 ± 5.0 v 10.3 ± 4.2 h; p = 0.978); or administration of postoperative morphine (25 [11-34) v 27 [10-39] g; p = 0.790). There was no difference between groups in total sufentanil administration and various preoperative psychologic and behavioral test levels nor in the time to reach bispectral index <50 during induction, except that personality type A demonstrated a longer induction time of 10 (8-12) minutes versus 6 (4-8) minutes in low-score patients.

CONCLUSION

A lower dose of sufentanil, compared with a standard dose, does not enhance fast-track conditions significantly.

Use of Provider Debriefing to Improve Fast-Track Extubation Rates Following Cardiac Surgery at an Academic Medical Center

When used in appropriate patient populations, fast-track extubation (FTE) anesthetic techniques and intensive care unit (ICU) protocols safely reduce intubation times, ICU length of stay, and resource utilization. The authors hypothesized that perioperative provider debriefing on success or failure of FTE would improve FTE success. This retrospective observational study included consecutive patients undergoing elective coronary artery bypass graft (CABG), valve, or combined CABG/valve surgery between February 2015 and May 2016 (N = 313). Throughout the intervention period, a briefing was distributed on postoperative day 1 to the anesthesiology providers responsible for operative care of the patient detailing success or failure of FTE and perioperative characteristics. The preintervention FTE success rate of 55.6% significantly improved to 72.8% in the intervention group ( P = .022). When combined with a continuous interdepartmental review process, provider debriefing improved FTE success. Perioperative provider debriefing requires minimal resources for implementation and can easily be replicated in other cardiac surgery centers.

Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery

Context:

Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay.

Aims:

The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients.

Settings and Design:

This prospective observational study was conducted in a 650-bedded tertiary cardiac center.

Subjects and Methods:

A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared.

Statistical Analysis Used:

Unpaired Student's t-test was used to compare the data.

Results:

The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001).

Conclusions:

A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.

Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience

BACKGROUND

The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications.

METHODS

From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVAD _ultra ) in 13 patients. After propensity score matching, we compared the LVAD _ultra group with a matched group (LVAD _match ) receiving conventional anesthesia management.

RESULTS

Patients in the LVAD _ultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival.

CONCLUSION

In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.

ICU Sedation: A Review of Its Pharmacology and Assessment

The need for appropriate sedation in the intensive care unit is paramount. Critically ill patients are exposed to multiple adverse stimuli stemming from both their illness and their environment. If left unchecked, these stimuli may often produce potentially harmful physiologic sequelae in patients who already have compromised physiologic reserve. The most useful sedative agents in such circumstances are those which are readily titratable and have manageable side effects. This typically focuses discussion on the intravenous administration of analgesic sedatives (opioids), anxiolytic and amnestic sedatives (benzodiazepines, barbiturates, etomidate, propofol), dissociative sedatives (ketamine), and the antipsychotic sedatives (butyrophenones). With ready titratability, though, comes the need for efficient monitoring and assessment of the degree of sedation. While no measure is without bias, this can effectively be done via the subjective means of a sedation scoring scheme or the more objective means of electrophysiologic measurements. It is the combination of pharmacological tools and consistent assessment which will allow the intensivist to readily achieve the desired sedation goal.

Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days

Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.

Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit

As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.