A retrospective multicenter study of operating room extubation and extubation timing after cardiac surgery

Eric W Etchill; Xiaoting Wu; Diane Alejo; Clifford E Fonner; Carol Ling; Neil Worrall; Eric Lehr; Francis Pagani; Terri Haber; Patty Theurer; Jeannie Collins-Brandon; Ravi Hira; James Brevig; Erika Mallory; Charles Maynard; Donald S Likosky; Glenn J R Whitman; IMPROVE Network

doi:10.1016/j.jtcvs.2024.09.057

A retrospective multicenter study of operating room extubation and extubation timing after cardiac surgery

J Thorac Cardiovasc Surg. 2024 Oct 18:S0022-5223(24)00928-0. doi: 10.1016/j.jtcvs.2024.09.057. Online ahead of print.

Authors

Eric W Etchill¹, Xiaoting Wu², Diane Alejo³, Clifford E Fonner⁴, Carol Ling², Neil Worrall⁵, Eric Lehr⁶, Francis Pagani², Terri Haber⁴, Patty Theurer⁷, Jeannie Collins-Brandon⁸, Ravi Hira⁹, James Brevig¹⁰, Erika Mallory³, Charles Maynard¹¹, Donald S Likosky², Glenn J R Whitman³; IMPROVE Network

Affiliations

¹ Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address: eetchil1@jhmi.edu.
² Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
³ Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
⁴ Maryland Cardiac Surgery Quality Initiative, Md.
⁵ Providence Heart Institute of Spokane, Sacred Heart Medical Center and Children's Hospital, Spokane, Wash.
⁶ Heart and Vascular Institute, Swedish Medical Center, Seattle, Wash.
⁷ Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Mich.
⁸ Cardiac Care Outcomes Assessment Program, Seattle, Wash.
⁹ Pulse Heart Institute Cardiology Services, Tacoma, Wash.
¹⁰ Providence Regional Medical Center Everett, Providence Heart Institute, Everett, Wash.
¹¹ Department of Surgery, University of Washington, Seattle, Wash.

PMID: 39426716
DOI: 10.1016/j.jtcvs.2024.09.057

Abstract

Background: In an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multicenter cohort study aimed to assess this by evaluating the outcomes of operating room (OR) extubation versus extubation within 6 hours of intensive care unit (ICU) arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity.

Methods: Patients undergoing on-pump cardiac surgery across 79 hospitals between 2011 and 2020 were included to (1) compare outcomes among OR extubation and early ICU extubation patients and (2) assess time to overall ICU extubation and outcomes.

Results: The overall study cohort comprised 163,982 patients, including 95,982 patients (OR extubation: n = 2529 [2.6%] and early ICU extubation: n = 93,453 [97.4%]) who underwent comparison of OR with early ICU extubation. After overlap weighting, patients with OR extubation had longer OR times (5.6 vs 5.1 hours, P < . 0001) and greater rates of reintubation (5.2% vs 2.9%, P = .003), prolonged ventilation (3% vs 2%, P = .021), reoperation for bleeding (1.5% vs 0.7%, P < .01), pneumonia (1.9% vs 1.1%, P < .006), and greater in-hospital mortality on multivariable regression (odds ratio, 1.34, P < .001). Patients with OR extubation at centers with low OR extubation rates (<10%, n = 60) had greater mortality (odds ratio, 1.6, P = .001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly.

Conclusions: Few patients who undergo cardiac surgery are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation after cardiopulmonary bypass. In addition, increased intubation time, in particular >22 hours, is associated with an increase in adverse outcomes.

Keywords: cardiac surgery; critical care; early extubation; enhanced recovery after surgery; extubation timing; operating room extubation.