Evaluation of early extubation (fast-track) after cardiac surgery in a post-anaesthesia recovery unit

Introduction: Early extubation, defined as extubation within 6 hours post-operation, was found to be safe and associated with decreased complications and costs. Recent enhanced recovery after surgery guidelines recommend early extubation for cardiac surgery patients. This retrospective study aimed to assess our institution’s extubation strategy and identify predictive factors of early extubation in our cardiac surgery patients. Methods: Our study included 13,807 adult patients who underwent cardiothoracic surgery from 2010-2019 at our institution. Forward stepwise multivariable logistic regression analysis was used on patients with complete data (n=10,783) to identify predictors of early extubation. Results: Of the 10,783 patients, 3740 (35%) were extubated within 6 hours post-operation. Early extubated patients were younger, had higher BMI and more likely to be fast track designated. These patients more frequently underwent isolated coronary artery bypass graft (CABG), isolated valve or adult congenital surgery than late extubated patients. Early extubated patients had higher incidence of coronary artery disease (CAD) and anxiety, and were less likely to have difficult intubation or require circulatory support post-surgery. Analysis of 10,783 patients showed BMI >30 (OR=1.840, 95% CI=1.624-2.083), fast track designation (OR=1.338, 95% CI=1.12-1.598) and having CAD (OR=1.107, 95% CI=1.007-1.217) to be predictive of early extubation. Data on patient transfer to the ICU were only available from 2014-2018. Within this sub-group of 7296 patients, variables predictive of early extubation included BMI >30 (OR=1.364, 95% CI=1.195-1.557), dayshift transfer to the ICU (OR=1.680, 95% CI=1.516-1.862), fast track designation (OR=1.397, 95% CI=1.115-1.751) and having isolated procedures such as CABG (OR=1.630, 95% CI=1.413-1.880) and valve surgery (OR=1.506, 95% CI=1.300-1.745). Conclusions: BMI >30, having fast track designation, and having CAD are associated with early extubation. When taking into account patient transfer to the ICU, BMI >30, having fast track designation, dayshift transfer to the ICU, and having isolated procedures such as CABG and valve surgery are associated with early extubation.

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Early Extubation and Fast-Track Anesthetic Technique for Endoscopic Cardiac Surgery

The Heart Surgery Forum ◽

10.1532/hsf98.20091151 ◽

2010 ◽

Vol 13 (3) ◽

pp. E190-E194 ◽

Cited By ~ 6

Author(s):

Maja Sostaric ◽

Borut Geršak ◽

Vesna Novak-Jankovic

Keyword(s):

Cardiac Surgery ◽

Fast Track ◽

Anesthetic Technique ◽

Early Extubation

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Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol

Critical Care Nurse ◽

10.4037/ccn2021189 ◽

2021 ◽

Vol 41 (3) ◽

pp. 14-24

Author(s):

Myra F. Ellis ◽

Heather Pena ◽

Allen Cadavero ◽

Debra Farrell ◽

Mollie Kettle ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Fast Track ◽

Early Extubation ◽

Control Approach ◽

Prolonged Intubation ◽

Care Processes ◽

Provider Practice ◽

The Impact

Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

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Early axtubation in cardiac surgery

Medicinski pregled ◽

10.2298/mpns1004183n ◽

2010 ◽

Vol 63 (3-4) ◽

pp. 183-187

Author(s):

Vojislava Neskovic ◽

Predrag Milojevic ◽

Dragana Unic ◽

Ivan Ilic ◽

Nada Popovic

Keyword(s):

Mechanical Ventilation ◽

Cardiac Surgery ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Fast Track ◽

Tracheal Extubation ◽

Early Extubation ◽

Cardiac Anesthesia ◽

Thoracic Epidural ◽

High Thoracic Epidural

Introduction An early extubation in cardiac surgery (fast track cardiac anesthesia) refers to mechanical ventilation during 1-6 hours after the intervention, the extubation criteria being the same as for any other surgery. Different protocols have been established for managing patients undergoing fast track anesthesia, with high-thoracic epidural anesthesia being increasingly used in the last few years. Material and methods Thirty-five consecutive patients scheduled for OPCAB surgery, who were planned for very fast track cardiac anesthesia (planned extubation within one hour after the end of the operation), were included in the study. Combined high-thoracic epidural and general anesthesia was performed in all patients, with bupivacain as a local anesthetic and inhalational or intravenous anesthetic used for general anesthesia. Results Thirty three of 35 patients (94.3%) were extubated early, with the mean duration of the mechanical ventilation of 56?92 minutes. Very fast track cardiac anesthesia was performed successfully in 24/35 (68,8%) patients; these patients had higher ejection fraction, lower Euroscore, shorter duration of the surgery, and fewer numbers of grafts, as compared to the patients extubated early. Euroscore was the only independent predictor of the early extubation (higher score - longer mechanical ventilation time). Discussion and conclusion Our results suggest that high-toracic epidural anesthesia enables successful early tracheal extubation in the population of patients scheduled for OPCAB cardiac surgery. We had no complications related to this type of anesthesia and very good perioperative results.

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Fast-track cardiac anaesthesia and early extubation

State of the Art Surgical Coronary Revascularization ◽

10.1093/med/9780198758785.003.0032 ◽

2021 ◽

pp. 174-180

Author(s):

Janet Martin ◽

Davy Cheng

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cardiac Surgery ◽

Fast Track ◽

Interdisciplinary Approach ◽

Cardiac Care ◽

Early Extubation ◽

Cardiac Anaesthesia ◽

Balanced Anaesthesia ◽

Intravenous Anaesthetics

‘Fast-track’ cardiac anaesthesia and recovery is the term given to a multicomponent intervention during cardiac surgery and postoperatively, with the ultimate goal of early extubation (within 1–6 hours) in order to reduce duration of mechanical ventilation, length of stay in the intensive care unit, and overall resource utilization. Key components of fast-track cardiac care include balanced anaesthesia (low-dose opioids together with inhaled or intravenous anaesthetics) and a time-directed extubation protocol. Fast-track cardiac care requires an interdisciplinary approach to anaesthesia during surgery, as well as a coordinated approach after surgery, in order to achieve early extubation and an overall streamlined approach to recovery and hospital discharge.

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