Balancing early extubation and rates of reintubation in cardiac surgical patients: where does the fulcrum lie?

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

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.

Balancing intubation time with postoperative risk in cardiac surgery patients - a retrospective cohort analysis

Introduction

Intubation time in patients undergoing cardiac surgery may be associated with increased mortality and morbidity. Premature extubation can have serious adverse physiological consequences. The aim of this study was to determine the influence of intubation time on morbidity and mortality in patients undergoing cardiac surgery.

Methods

We performed a retrospective analysis of data on 1,904 patients undergoing isolated coronary artery bypass grafting (CABG) and stratified them by duration of intubation time after surgery - 0-6, 6-9, 9-12, 12-24 and over 24 hours. Postoperative complications risk analysis was performed using multivariate logistic regression analysis for patients extubated ≤12 and >12 hours.

Results

Intubation percentages in each time cohort were as follows: 0-6 hours - 7.8%, 6-9 hours - 17.3%, 9-12 hours - 26.8%, 12-24 hours - 44.4% and >24 hours - 3.7%. Patients extubated ≤12 hours after CABG were younger, mostly males, more often smokers, with lower preoperative risk. They had lower 30-day mortality (2.02% vs 4.59%, P=0.002), shorter hospital stay (7.68±4.49 vs 9.65±12.63 days, P<0.001) and shorter intensive care unit stay (2.39 vs 3.30 days, P<0.001). Multivariate analysis showed that intubation exceeding 12 hours after CABG increases the risk of postoperative delirium (OR 1.548, 95% CI 1.161-2.064, P=0.003) and risk of postoperative hemofiltration (OR 1.302, 95% CI 1.023-1.657, P=0.032).

Conclusion

Results indicate that risk of postoperative complications does not increase until intubation time exceeds 12 hours. Shorter intubation time is seen in younger, men and smokers. Intubation time >12 hours is a risk factor for postoperative delirium and hemofiltration after cardiac surgery.