Impact of immediate versus delayed tracheal extubation on length of ICU stay of cardiac surgical patients, a randomized trial

Moataz Salah, Hisham Hosny, Maged Salah, Hoda Saad, Moataz Salah, Hisham Hosny, Maged Salah, Hoda Saad

Abstract

Introduction: Ultra-fast track anaesthesia aims at immediate extubation of cardiac surgical patients at the end of the operation. This study compares the effect of ultrafast track anesthesia versus continued postoperative mechanical ventilation on the intensive care unit length of stay.

Methods: Fifty-two elective adult patients were randomly allocated into ultrafast track anaesthesia and conventional groups by computer-generated random numbers. Redo operations, pre-operative intubation, uncontrolled diabetes, shock/left ventricular ejection fraction < 45%, pulmonary artery systolic pressure >55mmHg, creatinine clearance -1, haemodynamic instability, or those with concerns of postoperative bleeding were excluded. Pre- and intra-operative management was similar and Logistic EuroSCORE II was calculated for all. Intra-operatively, haemodynamic parameters, urine output, oxygen saturation, arterial blood gas analysis, 5-lead electrocardiogram, operative bypass- and cross-clamp time, and opioid consumption were collected. Postoperatively, patients were compared during their intensive care unit stay. Data were analysed by χ²/Fischer exact, unpaired student's t-test, univariate two-group repeated measures with post hoc Dunnett's test, and Mann-Whitney U tests as appropriate. p < 0.05 was considered significant.

Results: Patients were comparable regarding their peri-operative characteristics and EuroSCORE. The intensive care unit stay was shorter in the ultrafast track anaesthesia group [57.4 (18.6) vs. 95 (33.6) h. p < 0.001], without increasing postoperative renal, respiratory complications rate or reopening rate.

Conclusions: In this single center study, ultrafast track anaesthesia decreased intensive care unit stay without increasing the rate of post-operative complications.

Keywords: ICU stay; cardiac anaesthesia; ultra fast track anaesthesia.

Conflict of interest statement

Disclosures None declared.

Figures

Table 1
Table 1
Perioperative diagnosis, operation, demographic data, co-morbidities, and lab findings. Data are presented as number (percentages), mean (SD) as appropriate. UFTA = ultra-fast track anesthesia; CHD = congenital heart disease; IHD = ischemic heart disease; RHD = rheumatic heart disease; ASD = atrial septal defect; AVR = aortic valve replacement; CABG = coronary artery bypass graft; MVR = mitral valve replacement; TVR = tricuspid valve replacement; VSD = ventricular septal defect; BMI = body mass index; SD = standard deviation; HTN = hypertension; DM = diabetes mellitus; COPD = chronic obstructive pulmonary disease; PHT = pulmonary hypertension; EF = ejection fraction; Hb = hemoglobin; Euroscore = European System for Cardiac Operative Risk Evaluation.
Table 2
Table 2
Intraoperative hemodynamics, ABG findings, intraoperative findings, and opioid usage. Data are presented as mean (standard deviation). UFTA = ultra-fast track anesthesia; SD = standard deviation; MAP = mean arterial pressure;  HR = heart rate; CVP = central venous pressure; SpO2 = arterial oxygen saturation; ABG = arterial blood gas;  pH = power of hydrogen; PO2 = arterial oxygen tension; PCO2 = arterial carbon dioxide tension; HCO3 = bicarbonate; OP = operative; CPB = cardiopulmonary bypass; AXC = aortic cross clamp.
Table 3
Table 3
Postoperative ICU course, pain score, and postoperative complications. Data are presented as mean (standard deviation), frequency (percentage) as appropriate. UFTA = ultra-fast track anesthesia; SD = standard deviation; ICU = intensive care unit; VAS = visual analogue score.

References

    1. Montes F R, Sanchez S I, Giraldo J C, Rincón J D, RincÓn I E, Vanegas M V. et al. The lack of benefit of tracheal extubation in the operating room after coronary artery bypass surgery. Anesth Analg. 2000;91:776–780.
    1. Berry P, Thomas S, Mahon S, Jackson M, Fox M, Fabri B. et al. Myocardial ischaemia after coronary artery bypass grafting: early vs late extubation. Br J Anaesth. 1998;80:20–20.
    1. Bainbridge D, Cheng D. Initial Perioperative Care of the Cardiac Surgical Patient. Semin Cardiothorac Vasc Anesth. 2002;6:229–236.
    1. Cheng DC, Karski J, Peniston C, Raveendran G, Asokumar B, Carroll J. et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial. Anesthesiology. 1996;85:1300–1310.
    1. Lazar HL, Fitzgerald CA, Ahmad T, Bao Y, Colton T, Shapira OM. et al. Early discharge after coronary artery bypass graft surgery: are patients really going home earlier? J Thorac Cardiovasc Surg. 2001;121:943–950.
    1. Le TW, Jacobsoh E. Pro: tracheal extubation should occur routinely in the operating room after cardiac surgery. J Cardiothorac Vasc Anesth. 2000;14:603–610.
    1. Horswel JL, Herber MA, Princ SL, Mac MJ. Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients. J Cardiothorac Vasc Anesth. 2005;19:282–287.
    1. Chamcha D, Horro JC, Nachamchi L, Sutte FP, Samuel LE, Trac CL. 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;24:780–784.
    1. Amirghofra A, Rayatpishe M, Rayatpishe S, Kavian M. A comparative study of immediate and late extubation after open heart surgery. Int Cardiovascular Res J. Safranek. 2007;1:42–49.
    1. Edgerto JR, Herber MA, Princ SL, Horswel JL, Michelso L, Mage MJ. Reduced atrial fibrillation in patients immediately extubated after off-pump coronary artery bypass grafting. Ann Thorac Surg. 2006;81:2121–2127.
    1. Borracc RA, Dayá R, Rubi M, Axelru G, Ocho G, Rodrígue LD. [Operating room extubation (ultra fast-track anesthesia) in patients undergoing on-pump and off-pump cardiac surgery]. Arch Cardiol Mex. 2006;76:383–389.
    1. Chen DCH, Karsk J, Penisto C, Asokuma B, Raveendra G, Carrol J, e al.. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996;112:755–764.
    1. Rodriguez Blanc YF, Candiott K, Gologorsk A, Tan F, Gique J, Barro ME. et al. Factors which predict safe extubation in the operating room following cardiac surgery. J Card Surg. 2012;27:275–280.
    1. Won DT, Chen DCH, Kustr R, Tibshiran R, Karsk J, Carroll-Munr J. et al. Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track cardiac anesthesia: a new cardiac risk score. Anesthesiology. 1999;91:936–936.
    1. Dors AG, Ross AI, Thiere J, Lupiañe B, Vranci JM, Vaccarin GN. et al. Consecutive Patients’: Feasibility, Safety and Predictors of When Not To Attempt It. J Cardiothorac Vasc Anesth. 2011;25:431–436.
    1. Constantinide VA, Tekki PP, Fazi A, Kau K, Leonar R, Plat M. et al. Fast-track failure after cardiac surgery: Development of a prediction model. Crit Care Med. 2006;34:2875–2885.
    1. Bruce PJ, Strak Z, Vane T, Jare M. Less Invasive Cardiac Anesthesia: An Ultra-Fast-Track Procedure Avoiding Thoracic Epidural Analgesia. Heart Surg Forum. 2003;E:107–110.
    1. Landon G, Pappalard F, Crescenz G, Alett G, Marchett C, Pol D. et al. The outcome of patients requiring emergency conversion from off-pump to on-pump coronary artery bypass grafting. Eur J Anaesthesiol. 2007;24:317–322.
    1. Kandasam A, Ramalinga SK, Simo HA, Arumugha S, Redd BD, Krupanand H. Ultra fast-tracking versus a conventional strategy in valve replacement surgery. Indian J Anaesth. 2013;57:298–300.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe