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

Abstract

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.

Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention

“…Whether this was due solely to higher rates of heart failure and current smoking remains unclear; however prolonged extubation time has been identified as an independent risk factor for increased mortality and adverse events. [40]…”

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair

“…This is not surprising given that open repair requires a laparotomy and manipulation of the pararenal aorta. However, this should figure prominently into any surgeon’s risk-benefit analysis given the morbidity carried by respiratory failure and prolonged intubation 20 .…”

Respiratory Rehabilitation in Patients with Abdominal Aortic Aneurysm Submitted to OPEN and EVAR Treatment: Predictive Factors of Postoperative Pulmonary Complications and Clinical Implications

“…The surgical act involves the reduction of the lung volumes, above all of the vital capacity and, to a lesser extent, of the residual lung capacity. Furthermore, it induces modifications of the thoracoabdominal movements: involving the abdominal muscles, the incision modifies the expiratory kinetics of the diaphragm and alters the synergy of the transverse diaphragm couple determining a basal hypoventilation, in addition to the pain related to the deep inspiration [13].The introduction of the EVAR procedure, with an access route that does not compromise the respiratory dynamics in the postoperative period, reduce postoperative morbidity and hospitalization length [14]. The aim of this work is to evaluate the predictive factors of respiratory complications associated with the traditional OPEN and EVAR method and the influence of rehabilitation protocol in the prevention and treatment of postoperative complications.…”