Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial

Abstract

BackgroundThe use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery.MethodsThis clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients’ depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented.ResultsDemographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001).ConclusionsCombined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.

Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step—But There Is Much Work to Be Done

“…[102][103][104] Various anesthetic and analgesic techniques have been used effectively, the unifying principle being the optimization of patients' physiology and pharmacology to facilitate extubation. [105][106][107][108] The use of a postanesthesia or high-dependency unit as an alternative to a traditional intensive care unit for low-risk patients has been described and may encourage early extubation in a safe and cost-effective manner. 96,109 Specific details will depend on each institution's local environment; however, the first step to successful implementation always will be the creation of a multidisciplinary team to develop and apply a site-specific perioperative protocol.…”

Establishment of an enhanced recovery after surgery protocol in minimally invasive heart valve surgery

“…Maintenance of adequate end-organ perfusion during the surgery, the restoration of physiological conditions such as normothermia and administration of shortacting anaesthetics allow on-table extubation. There are different ways to perform fast-track anesthesia [24]. Our protocol did not only address on-table extubation, but also focus on the early postoperative patient comfort.…”

Patients should be extubated in the operating room after routine cardiac surgery: An inconvenient truth

“…[13][14][15] The development and endorsement of clinical algorithms that support OR extubation require multidisciplinary engagement. 3,[9][10][11] For some patients, the benefit may be clearly superior to interval extubation, but for some more complex cases, the benefit may be noninferior. Choice of anesthetic and sedation, ventilatory management, and nursing staff and respiratory therapist availability all play important roles in maintaining commitment to the goal.…”

“… 1 , 2 , 3 , 4 , 6 , 7 , 8 Simultaneously, sporadic experience with safe extubation in the operating room (OR) following cardiac surgery was applied in a limited manner to off-pump coronary artery bypass grafting and selected operations performed on cardiopulmonary bypass, such as minimally invasive procedures. 3 , 9 , 10 This has now been extended to patients following routine cardiac surgery, particularly those without significant coagulopathy and without intraoperative ventilatory or oxygenation aberrations with no anticipated difficulty in the use of mask ventilation or need for urgent reintubation. 3 , 9 , 10 , 11 Today, there is growing support for safe routine extubation performed in the OR based on an increasing number of patient outcome benefits.…”