The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

IMMEDIATE EXTUBATION OF THE CARDIAC SURGICAL PATIENT: THE ROLE OF RESPIRATORY THERAPY IN THE PERIOPERATIVE PERIOD

E. Crimmins1, J. Gonzalez1, S. L. Cozine1


Background

Early tracheal extubation (<8 hours) following cardiac surgery has been associated with reduced cost and ICU length of stay (LOS). However, immediate extubation (IE) in the operating room itself is infrequently performed out of concern for respiratory complications, instability and bleeding. We have previously shown IE reduces ICU and hospital LOS in a series 943 revascularization patients. Care of the postoperative cardiac surgery patient is challenging and possibly more labor-intensive in the non-intubated patient. Therefore, the involvement of a skilled respiratory therapy team (RT) is crucial to the success of an early extubation program. We present a large series of IE patients.

Methods
A retrospective review of our institutional Society of Thoracic Surgeons database from May 2003 through April 2007 identified 2378 cardiac surgery patients. All surgeries were performed at a 63-bed cardiovascular surgery specialty hospital with a goal of immediate tracheal extubation when feasible. The RT was responsible for preoperative evaluation and patient instruction. Guidelines used for postoperative mechanical ventilation and weaning allowed for greater therapist autonomy. Non-intubated patients were closely managed by RT to assure adequate respiratory function and limit the need for reintubation.

Results
Overall 1180 patients (49.6%) were extubated immediately. Reintubation was required in 68 (2.86%) for various reasons, including re-exploration. Extubation varied with the type of surgery and occurred in 71.3% of OPCAB and 39.4% of CABG surgeries. For other procedures using cardiopulmonary bypass the IE rate was 28.7%. 1015 OPCAB patients were further analyzed and a significant difference was observed in ICU hours (p<0.001) but not hospital LOS, reintubation or mortality.

Discussion
In this series of 2378 cardiac surgical patients we demonstrate a high rate of immediate OR extubation in both on and off-pump surgeries with no increase in adverse events over intubated patients. Additionally, we show significant a reduction in ICU duration in OPCAB patients. The paradigm of routine IE requires coordination of anesthesia and respiratory services and can be accomplished safely and with significant benefit for cardiac surgical patients.


Chart 1. Immediate OR Extubation by Type of Surgery
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