Early extubation after abdominal aortic reconstruction

Stone, William M.; Larson, Joel S.; Young, Michelle; Weaver, Amy L.; Lunn, Jeffrey J.

doi:10.1016/s1053-0770(98)90327-5

Cited by 12 publications

(5 citation statements)

References 2 publications

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“…Similar conclusions were drawn by Stone et al when they evaluated the outcomes of patients who underwent immediate extubation (<2 hours) and found that reintubation rates of 4.8% with 1.6% mortality. 12 Despite these studies concluding that early extubation is safe, it should be noted rapid extubation was widely achieved, even in Cohen’s delayed cohort (median time 340 minutes). To further evaluate this topic, a study of 191 Japanese patients evaluated patients extubated on the day of surgery compared to those extubated later, with median post-operative extubation times of 2.6 versus 17.4 hours respectively.…”

Section: Discussionmentioning

confidence: 99%

Early extubation reduces respiratory complications and hospital length of stay following repair of abdominal aortic aneurysms

Zettervall

Soden

Shean

et al. 2017

Journal of Vascular Surgery

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Introduction Early extubation following cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (Endovascular (EVAR): 77–97%, Open: 30–70%) following repair of intact abdominal aortic aneurysms (AAA). However, the effects extubation practices on patient outcomes after repair of AAAs are unclear. Methods All patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003–2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (Operating Room, <12 hours, >12 hours) and open repair (Operating Room, <12 hours, 12–24 hours, >24 hours). Prolonged hospital stay was defined as >2 days following EVAR and >7 days following open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified. Results 5774 patients were evaluated (EVAR: 4453, Open: 1321). Following both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12-hour delay in extubation: respiratory (EVAR-OR: 4.3, 95% CI: 3.0–6.1; Open-OR: 1.8, 95% CI: 1.5–2.2), prolonged hospital stay (EVAR-OR: 2.7, 95% CI: 2.0–3.8; Open–OR: 1.3, 95% CI:1.1–1.4), and discharge to SNF (EVAR-OR: 2.0, 95% CI: 1.5–2.8; Open-1.4, 95% CI 1.1–1.6). Predictors of extubation outside of the operating room following EVAR included: increasing age (OR:1.5, 95% CI:1.2–1.8), congestive heart failure (CHF) (OR:1.9, 95% CI:1.2–3.0), chronic obstructive pulmonary disease (OR: 2.0, 95% CI: 1.4–2.9), symptomatic aneurysm (OR: 3.8, 95% CI 2.3–5.7), and increasing diameter (OR: 1.01, 95% CI: 1.01–1.01). Following open repair increasing age (OR: 1.4, 95% CI: 1.1–1.6), CHF (OR: 1.8, 95% CI: 1.01–3.3), dialysis (OR: 2.8, 95% CI: 1.7–70), symptomatic aneurysm (OR 2.8, 95% CI: 1.9–4.3), and hospital practice patterns (OR: 1.01, 95% CI: 1.01–1.01) were predictive of extubation outside of the operating room. Conclusions The benefits of early extubation in cardiac patients are also seen following AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and improve patient outcomes.

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Section: Discussionmentioning

confidence: 99%

Early extubation reduces respiratory complications and hospital length of stay following repair of abdominal aortic aneurysms

Zettervall

Soden

Shean

et al. 2017

Journal of Vascular Surgery

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“…7–9,15 Various centers have published protocols for perioperative management after OAR with the goal of shortening LOS while maintaining patient safety. 16,17 Ours is the first large study focusing specifically on timing of extubation for this patient population.…”

Section: Discussionmentioning

confidence: 99%

“…16,17 Ours is the first large study focusing specifically on timing of extubation for this patient population. 9 Previous literature describing comparative costs of endovascular AAA repair (EVAR) vs OAR have shown that EVAR can be cost-saving in the short-term mainly due to the significantly shorter hospital LOS, but there are conflicting data regarding the long-term cost-effectiveness of EVAR as a result of surveillance and reintervention costs. 2,4,6 By further helping to decrease the costs and LOS for OAR and suprainguinal bypass, we can further decrease this disparity and make open abdominal procedures more comparable to endovascular procedures.…”

Section: Discussionmentioning

confidence: 99%

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Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative

David

Brooke

Hanson

et al. 2017

Journal of Vascular Surgery

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Objective Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery. Methods We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 in hospitals participating in the Vascular Quality Initiative (VQI). Our primary outcome was prolonged LOS (>7 days), and the secondary outcome was respiratory complications (pneumonia or reintubation). The association between extubation timing and outcomes was assessed using multivariable logistic regression mixed-effects models that adjusted for confounding factors at the patient and procedure level. A variable importance analysis was conducted using a chi-pie framework to identify factors contributing to the variability of extubation timing. Results The 7171 patients undergoing abdominal aortic surgery were a mean age of 65.4 (standard deviation, 10.2) years, and 63% were male. Extubation occurred (1) in the operating room (76.3%), (2) <12 hours (10.9%), (3) 12 to 24 hours (7.2%), or (4) >24 hours (5.6%) after surgery. Hospitals in the top quartile for case volume had the highest percentage of patients extubated in the operating room (82.8%). Patients least likely to be extubated in the operating room were older, more likely to have chronic obstructive pulmonary disease, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS (<12 hours: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2–1.7; 12–24 hours: OR, 2.1; 95% CI, 1.7–2.7; >24 hours: OR, 5.3; 95% CI, 4.0–6.9), and pulmonary complications (<12 hours: OR, 1.9; 95% CI, 1.4–2.6; 12–24 hours: OR, 2.6; 95% CI, 1.8–3.6; >24 hours: OR, 9.6; 95% CI, 7.1–13.0) compared with those extubated in the operating room. Subset analysis of patients extubated in the operating room or <12 hours showed that extubation out of the operating room was associated with prolonged LOS (OR, 1.4; 95% CI, 1.2–1.7) and pulmonary complications (OR, 1.8; 95% CI, 1.3–2.5). The variable importance analysis demonstrated that EBL (26%) and procedure time (24%) accounted for half of the variation in extubation timing. Conclusions Extubation in the operating roomis associated with shorter LOS and morbidity after open aortic surgery. EBL, procedure time, and center variation account for variability in extubation timing. These data advocate for standardized perioperative respiratory care to reduce variation, improve outcomes, and reduce LOS.

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“…This combination of circumstances may lead to post-extubation upper airway obstruction in patients with narrow upper airways such as those with obesity and/or OSA. In support of this concept, several authors have noted that attempts to fast track extubation after cardiac surgery56 57 and abdominal aneurysm reconstruction58 are less successful in obese patients. The use of non-invasive positive pressure ventilation applied immediately after extubation appears a useful strategy to allow successful weaning and extubation in difficult to wean patients59 or to prevent re-intubation in high-risk patients.…”

Section: Obesity and Obstructive Sleep Apnoeamentioning

confidence: 99%