Early is Good, But is Immediate Better? Considerations in Fast-Track Extubation After Cardiac Surgery

WITH THE development of enhanced recovery after surgery protocols, and the extension of these practices to the cardiac surgery realm, we constantly are examining the perioperative care of cardiac surgical patients. Of the enhanced recovery measures, the topic of extubation practices continues to be debated. It has been described well that fast-track extubation is both beneficial and safe for the appropriate candidate after cardiac surgery.1Horswell JL Herbert MA Prince SL et al.Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients.J Cardiothorac Vasc Anesth. 2005; 19: 282-287Google Scholar,2Chamchad D Horrow JC Nachamchik L et al.The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.J Cardiothorac Vasc Anesth. 2010; 24: 780-784Google Scholar The article by Brovman et al.3Brovman, et al. [e-pub ahead of print]. J Cardiothorac Vasc Anesth. Accessed.Google Scholar continued the discussion surrounding the topic of extubation after cardiac surgery by adding new data regarding the risks associated with intubation after cardiac surgery. For many years there has been a trend toward earlier and earlier extubation, first with findings that showed 12 hours as an important inflection point in which risk increases.4Kotfis K Szylinska A Listewnik M et al.Balancing intubation time with postoperative risk in cardiac surgery patients: A retrospective cohort analysis.Ther Clin Risk Manag. 2018; 14: 2203-2212Google Scholar The discussion began as a desire to shorten the time of postcardiac surgery intubation from days to hours.5Fitch ZW Debesa O Ohkuma R et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Google Scholar,6Cove ME Ying C Taculod JM et al.Multidisciplinary extubation protocol in cardiac surgical patients reduces ventilation time and length of stay in the intensive care unit.Ann Thorac Surg. 2016; 102: 28-34Google Scholar However, now the interest in further pushing this point has brought forth some promoting immediate extubation in the operating room (OR) versus the more standard fast-track extubation within a few hours after surgery in the intensive care unit (ICU). Here, in this month's edition of the Journal, the authors found that the classic time point of 6 hours after surgery still was a safe goal for which to aim.3Brovman, et al. [e-pub ahead of print]. J Cardiothorac Vasc Anesth. Accessed.Google Scholar Although this topic has been studied previously, results and data that replicate prior findings are important, as they lend even more validity to the findings as reported here by the authors. As anesthesiologists, we have a foundation in patient safety. Although this foundation drives the desire to provide excellent and safe care, the topic of extubation after cardiac surgery has been a debated topic, often composed of opinion intermixed with objective data. There seems to be convincing data, in addition to the associated article here, that extubation within 6 hours after arrival in the ICU is a meaningful standard for a fast track.7Richey M Mann A He J et al.Implementation of an early extubation protocol in cardiac surgical patients decreased ventilator time but not intensive care unit or hospital length of stay.J Cardiothorac Vasc Anesth. 2018; 32: 739-744Google Scholar Extubation in a shorter time seems to be possible, as there are groups that have successfully published their experience of earlier extubation with reasonable outcomes, though their approach is not applicable universally to all cardiac surgical patients.8Subramaniam K DeAndrade DS Mandell DR et al.Predictors of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. 2017; 154 (e2): 1656-1665Google Scholar, 9Rai N Malewar T Rai N. Operating room (OR) extubation after off pump coronary artery bypass grafting surgery: Its feasibility and effect on post operative complication: A prospective study.Int J Res Med Sci. 2018; : 4097-4101Google Scholar, 10Totonchi Z Azarfarin R Jafari L et al.Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: A randomized clinical trial.Anesth Pain Med. 2018; 8: e80158Google Scholar And certainly here, the population in whom the early extubation target is intended, is not all cardiac surgery patients.11Murphy WP Butterworth JF The "bespoke" recovery: Available when the tailoring is guided by experience and high-quality data.J Thorac Cardiovasc Surg. 2017; 154: 1666-1667Google Scholar It is likely that most, if not all, practicing groups intend on maintaining intubation past the 6-hour mark for certain procedure types, such as transplantation, left ventricular assist devices, multivalve repeat sternotomies, etc. As the practice of cardiac anesthesiology continued to mature, it was only natural that the amount of time to awakening, extubation, and mobilization of postsurgical patients would decrease.12Singh KE Baum VC. Pro: Early extubation in the operating room following cardiac surgery in adults.Semin Cardiothorac Vasc Anesth. 2012; 16: 182-186Google Scholar Although there is a continued pressure to do so, it is not entirely clear that the motivation to further move the extubation goalposts is the result of a desire to improve patient outcomes and more of a desire for the provider to have some personal feeling of accomplishment. Of course, any time one undertakes a course that is of no direct benefit to the patient, there should be questions about the motivation. At this time, the desire to extubate immediately after the procedure may be the result of 3 motivators—shorter ICU length of stay, reduced costs and saved money, or perhaps allowed the physicians to “feel” like they are doing a good job. Initial experiences and reports with immediate extubation in the OR were based mostly on the off-pump coronary artery bypass graft patient population, and did not demonstrate increased risks of respiratory complications, reintubation, rebleeding and/or reoperation, cardiac arrhythmias, or cardiac ischemia. Horswell et al. evaluated the safety of immediate extubation in the OR on 514 patients undergoing off-pump coronary artery bypass graft, and, in addition to finding this to be a safe practice, they found ischemia incidence and mortality risk less than the Society of Thoracic Surgeons (STS) average (1.9% below the STS predicted risk of mortality of 3.3% ± 4.7% for that population).1Horswell JL Herbert MA Prince SL et al.Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients.J Cardiothorac Vasc Anesth. 2005; 19: 282-287Google Scholar Chamchad et al.2Chamchad D Horrow JC Nachamchik L et al.The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.J Cardiothorac Vasc Anesth. 2010; 24: 780-784Google Scholar expanded the study of this practice to include both on- and off-pump coronary artery bypass graft, valve repair or replacement, or combined surgery patients. It was important to assess the addition of cardiopulmonary bypass and its impact on the safety of immediate extubation. Additionally, the authors examined durations of ICU and hospital stay for those extubated in the OR versus standard fast-track extubation within 6 hours of admission to the ICU. Not only did they report similarly low rates of reintubation similar to previously published studies, but they also reported in those selected for immediate extubation, there was a shorter ICU stay by 23 hours (p < 0.0001), and a shorter hospital length of stay by 0.8 days (p < 0.0001). Of course, there are non–patient-related factors to consider when making decisions on whether or not to extubate a postcardiac surgery patient in the OR. Depending on the layout of the perioperative area and the proximity of the OR to the ICU, it may not be considered safe to extubate immediately before a long transport with limited monitoring and airway equipment. If pain is not controlled adequately, or the patient experiences emergence delirium, this also can make for a difficult transport to the ICU. Many centers have developed a multidisciplinary handoff for the OR to ICU transition. It sometimes can be more difficult for the nursing staff to get a patient settled when they are not sedated and intubated, which may make handoff more difficult and the nurse caring for the patient may be distracted and/or unable to listen to pertinent details of the patient's operative course. Although the reported benefits of immediate extubation in the OR have been described, some workflow and institutional barriers may prevent it from being practical or safe. Given the way that the costs of healthcare continue to increase, cost reduction is a noble goal. However, it is not clear that extubation will change the overall costs.13Sullivan BL. Con: Early extubation in the operating room following cardiac surgery.Semin Cardiothorac Vasc Anesth. 2012; 16: 187-189Google Scholar Certainly, in the inpatient Diagnosis-Related Grouping based reimbursement process, there are no changes to patient charges or hospital reimbursement if the patient is extubated before going to the ICU. It is possible that if a hospital system is not taking postcardiotomy patients to the ICU if they are extubated, it could reduce hospital system costs but not patient cost. As well, the hospital is not going to reduce their workforce of respiratory therapists or their ventilator inventory, no cost savings there. As previously mentioned, unless the ICU is skipped all together, there may or may not be a meaningful change in ICU length of stay depending on the practice.7Richey M Mann A He J et al.Implementation of an early extubation protocol in cardiac surgical patients decreased ventilator time but not intensive care unit or hospital length of stay.J Cardiothorac Vasc Anesth. 2018; 32: 739-744Google Scholar Many institutions have issues with moving patients from the ICU to a lower level of care, and shortening the period of intubation will work only if there is capacity for patients to move through at a faster rate. Even a study designed to demonstrate the improved throughput that ultrafast-track anesthesia can provide, showed a statistically significant difference; the actual clinical difference it provides, 3.96 ± 0.73 days versus the conventional group at 4.34 ± 0.66 days is likely not relevant.14Nagre AS Jambures NP. Comparison of immediate extubation versus ultrafast tracking strategy in the management of off-pump coronary artery bypass surgery.Ann Card Anaesth. 2018; 21: 129-133Google Scholar That is a much more complex problem than removing a breathing tube, specifically when readmission to the ICU after cardiac surgery increases the risks of morbidity and mortality.15Kogan A Cohen J Raanani E et al.Readmission to the intensive care unit after "fast-track" cardiac surgery: Risk factors and outcomes.Ann Thorac Surg. 2003; 76: 503-507Google Scholar,16Jian L Sheng S Min Y et al.Risk factors for endotracheal re-intubation following coronary artery bypass grafting.J Cardiothorac Surg. 2013; 8: 208Google Scholar Brovman et al., in a large retrospective analysis, have shown that early extubation, as defined by the authors as <6 hours after completion of the cardiac surgical procedure, is safe. Not only is it safe, but also perhaps beneficial to the patient.3Brovman, et al. [e-pub ahead of print]. J Cardiothorac Vasc Anesth. Accessed.Google Scholar It is our opinion that in the absence of strong, objective, prospectively acquired data, that current practice of extubation within 6 hours should be maintained. At a time in which such strong data exists that one should be compelled to change their practice, then it will be reflected in guidelines and recommendations. This editorial is in many ways an update to that published 4 years ago, remarking on the work that showed no risk in extubating in <6 hours.17Goeddel LA Hollander KN Evans AS. Early extubation after cardiac surgery: A better predictor of outcome than metric of quality?.J Cardiothorac Vasc Anesth. 2018; 32: 745-747Google Scholar Until the time comes when data for subpopulations show which patients specifically will benefit from earlier extubation, one of the strengths of anesthesia practice is the freedom to do so in a way that is best for the individual patient and within the provider's experience. Although the debate will continue, we argue that there is at this time, there is not adequate evidence to change the current practice of leaving patients intubated for a brief postoperative (<6-hour) period. None. Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional StudyJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 5PreviewIt is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery. Full-Text PDF