The Impact of Bispectral Index Versus End-Tidal Anesthetic Concentration-Guided Anesthesia on Time to Tracheal Extubation in Fast-Track Cardiac Surgery

Background Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population. Methods Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation < or = 10 h (early) or > 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups. Results One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intraaortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-microg/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-microg/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test). Conclusions In this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery.

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Bispectral index-guided anesthesia on time to tracheal extubation after onpump cardiac surgery

Critical Care ◽

10.1186/cc14573 ◽

2015 ◽

Vol 19 (Suppl 1) ◽

pp. P493

Author(s):

E Kaval ◽

P Zeyneloglu ◽

A Camkiran ◽

A Sezgin ◽

A Pirat ◽

...

Keyword(s):

Cardiac Surgery ◽

Bispectral Index ◽

Tracheal Extubation

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Measurement of End-Tidal Carbon Dioxide in Spontaneously Breathing Children After Cardiac Surgery

American Journal of Critical Care ◽

10.4037/ajcc2011537 ◽

2011 ◽

Vol 20 (5) ◽

pp. 388-394

Author(s):

Carmen Caroline Rasera ◽

Pedro Miguel Gewehr ◽

Adriana Maria Trevisan Domingues ◽

Fernando Faria Junior

Keyword(s):

Carbon Dioxide ◽

Cardiac Surgery ◽

Blood Gas Analysis ◽

Tracheal Extubation ◽

Supplemental Oxygen ◽

Pulmonary Complications ◽

Gas Analysis ◽

End Tidal Carbon Dioxide ◽

End Tidal ◽

Spontaneously Breathing

BackgroundRespiratory monitoring is important after surgery to prevent pulmonary complications. End-tidal carbon dioxide (Petco2) measurement by capnometry is an indirect and noninvasive measurement of Pco2 in blood and is accepted and recognized in critical care.ObjectivesTo determine the correlation and level of agreement between Petco2 and Paco2 in spontaneously breathing children after cardiac surgery and to determine whether Petco2 measured by using tidal volume (Vt-Petco2) or vital capacity (VC-Petco2) shows more or less significant correlation with Paco2.MethodsVt-Petco2 and VC-Petco2 by capnometry and Paco2 by blood gas analysis were measured once a day after tracheal extubation. The determination coefficient and degree of bias between the methods were assessed in children with and without supplemental oxygen.ResultsA total of 172 Vt-Petco2, VC-Petco2, and Paco2 values from 48 children were analyzed. The overall coefficients of determination were 0.84 (P < .001) for Vt-Petco2 and Paco2 and 0.62 (P = .02) for VC-Petco2 and Paco2. The mean gradient for Paco2 to Petco2 in all groups increased with the increase in supplemental oxygen; the gradient was significantly larger in the groups given 2 to 5 L of oxygen per minute.ConclusionsIn spontaneously breathing children, Vt-Petco2 provided a more accurate estimate of Paco2 than did VC-Petco2, especially in children given little or no supplemental oxygen. The difference between the methods was significantly larger in the groups given 2 to 5 L of oxygen per minute.

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Increased Risk of Intraoperative Awareness in Patients with a History of Awareness

Anesthesiology ◽

10.1097/aln.0000000000000023 ◽

2013 ◽

Vol 119 (6) ◽

pp. 1275-1283 ◽

Cited By ~ 33

Author(s):

Amrita Aranake ◽

Stephen Gradwohl ◽

Arbi Ben-Abdallah ◽

Nan Lin ◽

Amy Shanks ◽

...

Keyword(s):

Relative Risk ◽

Bispectral Index ◽

Randomized Clinical Trials ◽

Linear Mixed Model ◽

Anesthetic Management ◽

Intraoperative Awareness ◽

Anesthetic Concentration ◽

Increased Risk ◽

History Of ◽

End Tidal

Abstract Background: Patients with a history of intraoperative awareness with explicit recall (AWR) are hypothesized to be at higher risk for AWR than the general surgical population. In this study, the authors assessed whether patients with a history of AWR (1) are actually at higher risk for AWR; (2) receive different anesthetic management; and (3) are relatively resistant to the hypnotic actions of volatile anesthetics. Methods: Patients with a history of AWR and matched controls from three randomized clinical trials investigating prevention of AWR were compared for relative risk of AWR. Anesthetic management was compared with the use of the Hotelling’s T2 statistic. A linear mixed model, including previously identified covariates, assessed the effects of a history of AWR on the relationship between end-tidal anesthetic concentration and bispectral index. Results: The incidence of AWR was 1.7% (4 of 241) in patients with a history of AWR and 0.3% (4 of 1,205) in control patients (relative risk = 5.0; 95% CI, 1.3–19.9). Anesthetic management did not differ between cohorts, but there was a significant effect of a history of AWR on the end-tidal anesthetic concentration versus bispectral index relationship. Conclusions: Surgical patients with a history of AWR are five times more likely to experience AWR than similar patients without a history of AWR. Further consideration should be given to modifying perioperative care and postoperative evaluation of patients with a history of AWR.

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Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-100213 ◽

2019 ◽

Vol 45 (1) ◽

pp. 22-26

Author(s):

Satoshi Hanada ◽

Atsushi Kurosawa ◽

Benjamin Randall ◽

Theodore Van Der Horst ◽

Kenichi Ueda

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Retrospective Study ◽

Spinal Anesthesia ◽

Operating Room ◽

Fast Track ◽

Elective Cardiac Surgery ◽

Anesthesia Technique ◽

High Spinal Anesthesia ◽

The Impact

Background and objectivesAlthough high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery.MethodsElective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days).ResultsIn the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084).ConclusionsHSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.

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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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