Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs

Badhwar, Vinay; Esper, Stephen A.; Brooks, Maria M.; Mulukutla, Suresh; Hardison, Regina M.; Mallios, Demetri; Chu, Danny; Wei, Lawrence M.; Subramaniam, Kathirvel

doi:10.1016/j.jtcvs.2014.07.037

Cited by 55 publications

(62 citation statements)

References 27 publications

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“…Badhwar et al 7 examined the outcomes and compared the costs of extubation in the operating room vs early extubation in the ICU after elective open cardiac surgery. They found that extubation in the operating room resulted in a >20% cost reduction for the entire hospital stay compared with early extubation in the ICU with no effect on the reintubation rate.…”

Section: Discussionmentioning

confidence: 99%

“…They found that extubation in the operating room resulted in a >20% cost reduction for the entire hospital stay compared with early extubation in the ICU with no effect on the reintubation rate. 7 …”

Section: Discussionmentioning

confidence: 99%

“…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%

“…Data on early vs late extubation of cardiac surgery patients after cardiopulmonary bypass has demonstrated significant reductions in ICU hours, postoperative LOS, and a >20% reduction in cost without an increase in reintubation rates. 7 In comparison, there is a paucity of data for vascular surgery patients undergoing elective open aortic procedures. 8,9 Extubation timing practices may be an important target for reducing LOS and complications from open aortic surgery.…”

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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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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

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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“…13,14 There is evidence to suggest that extubation within the operating room (OR) itself may additionally reduce hospital LOS and costs without increasing major adverse event (MAE) rates or the need for reintubation. 15,16 Although there is an established association between prolonged mechanical ventilation and delirium, the nature of this association in the cardiac surgery patient is uncertain. 2 Evidence suggests that mechanical ventilation may be an independent risk factor for developing delirium; however, there are likely patient-specific and procedure-related factors confounding both the decision to extubate and the occurrence of postoperative delirium.…”

Section: Perspectivementioning

confidence: 99%

Association of earlier extubation and postoperative delirium after coronary artery bypass grafting

Moran

Maguire

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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Fast-track cardiac care for adult cardiac surgical patients

Wong

Lai

Chee

et al. 2016

Cochrane Database of Systematic Reviews

139

109

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Background Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation a er surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and e ective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016. Objectives To determine the safety and e ectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both.

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Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs

Abstract: After cardiac surgery, OR extubation is safe and might provide improvement in length of stay and cost compared with early postoperative ICU extubation.

Cited by 55 publications

References 27 publications

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

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

Association of earlier extubation and postoperative delirium after coronary artery bypass grafting

Fast-track cardiac care for adult cardiac surgical patients

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