Early or fast-track extubation is not a novel concept. The American College of Cardiology and the American Heart Association recommended early postoperative extubation of low- to medium-risk CABG patients in 2011, based on research that showed low rates of reintubation and no decrease in quality of life with the strategy (Circulation 2011;124:2610-2642). Early extubation, often defined as extubation within six or 12 hours after leaving the OR, offered the added potential benefit of a shorter length of stay in the intensive care unit (ICU) and hospital.
Some cardiac surgeons and anesthesiologists saw potential beyond just CABG, low-risk patients and the ICU. They developed protocols to allow early extubation for adults undergoing minimally invasive mitral valve procedures, for instance, and for children in need of surgery to repair diseased hearts. With careful anesthesia management and team work, they now safely achieve high rates of extubation—in the OR and in many types of patients.
“Our position is, not only can you apply fast-tracking globally to everybody and show that there is an outcome benefit and a cost benefit, but now you can apply that even in the operating room,” says Vinay Badhwar, MD, chief of adult cardiac surgery at the University of Pittsburgh Medical Center. “In a fairly unselected way, we were able to extubate nearly all cardiac operations provided they were not in shock, emergent or otherwise medically or clinically inappropriate for any kind of fast-track extubation due to instability.”
Adults are not the only beneficiaries. Nationwide Children’s Hospital in Columbus, Ohio, began exploring ways to initiate early extubation in pediatric patients as far back as a decade ago. “We extubate on average 70 to 80 percent of our patients on the OR table,” estimates Aymen N. Naguib, MD, director of anesthesiology at the Heart Center at Nationwide Children’s. “We feel very comfortable with that.”
A pilot takes off
Inspired by their experiences with early extubation after minimally invasive and robotic cardiac surgeries, Badhwar and his colleagues devised a small pilot program enrolling low-risk cardiac surgery patients to evaluate the safety and effectiveness of OR extubation. Its success prompted them to broaden the scope to include more patients.
“We looked at the literature and realized there was very spotty experience that is usually off-pump CABG cases or minimally invasive cases,” with little that addressed the broader patient population, he says. “Surgery that involves multivalve operations, redos, third-time redos. Pretty much everybody.”
The Pittsburgh team designed a propensity-matched analysis of patients who underwent cardiac operations between January 2012 and June 2013 and who were extubated within 12 hours (J Thorac Cardiovasc Surg 2014;148:3101-3109). They assessed three groups: those extubated in the OR (165 patients), those extubated in the ICU within 12 hours (487 patients, group one) and those extubated in the ICU within six hours (356 patients, group two). In January 2012, the hospital expanded its standardized protocol for anesthesia in cardiac surgical procedures to include all nonemergency operations.
They found no difference in operating times between the three groups or in the reintubation rate. The time between the completion of the surgery and exiting the OR, or from “drapes off” to “wheels out,” was only two to three minutes more in the OR extubation group.
Patients extubated in the OR had shorter postoperative ICU times compared with groups one and two and a shorter length of stay from surgery completion to discharge. Rates of discharge directly to home without skilled nursing rehabilitation were about 15 percentage points higher for patients extubated in the OR compared with groups one and two. And overall costs with OR extubation came in lower, at a median $3,055 vs. $3,977 for group one and $3,025 vs. $3,877 for group two.
“The outcome is really staggering,” Badhwar says. “The patients who come out of surgery are talking to their families, they are taking sips and they are sitting in a chair on the same day regularly for all forms of cardiac surgery. The perioperative complications—gastrointestinal, pulmonic—those things have gone way down.”
The strategy has resulted in lower costs and higher patient satisfaction, positives the healthcare system hopes to see spread across its hospitals. “We have a protocol that is being shared with our sister institutions and it is being propagated in a slow but purposeful way,” Badhwar says.
Balancing act with kids
Anesthesia blunts the inflammatory stress response that cardiopulmonary bypass and other cardiac surgeries trigger. While those responses are well defined in adults, they are much more variable in children. Children, like adults, potentially benefit from early extubation, if it is safe. That requires a delicate balance between drugs that are strong enough to blunt the stress response and protect pediatric patients yet short-acting or at a low enough dose to allow for accelerated recovery.
Naguib’s teams has been systematically unraveling questions about extubation in the cardiac OR for pediatric patients, from benefits and risks to long-term outcomes. For instance, by retroactively analyzing data on 874 patients who underwent congenital heart surgery or cardiopulmonary bypass at their center, they determined that OR extubation shortened the ICU length of stay on average 3.6 days vs. 13.2 days for patients not extubated in the OR.
They had an overall extubation rate of 70 percent. But drilling down, they found that age was a predictor of success. While 85 percent of patients one year or older were successfully extubated in the OR, only 56 percent of those under 12 months were.
“Obviously patients who had longer bypass time, longer cross-clamp time in the OR and the more sick would fail the extubation,” Naguib says. “That took us to the next level. Can we do this without stressing the kids? … When they are under surgery and even though they are asleep and not feeling anything, [will] their bodies secrete certain stress hormones?”
In a Goldilocks and the Three Bears design, Naguib’s team looked at three different anesthetic techniques in children treated with cardiopulmonary bypass and OR extubation in a prospective, randomized double-blind trial (Pediatr Crit Care Med 2013;14:1-10). Sixteen children received low-dose fentanyl with placebo, 17 had high-dose fentanyl and 15 had low-dose fentanyl and dexmedetomidine (Precedex, Orion Pharma). They took blood samples to measure stress response.
They hypothesized that the low dose would be “too soft,” allowing a higher stress response that might lead to complications; the high dose would be “too hard,” blunting the stress response but not allowing early extubation; and the dual dose might be “just right,” combining a lower stress response with a higher chance of extubation in the OR. Results showed the low-dose group had the highest stress markers, the high dose group the lowest stress markers and the combination group also had a low level of stress markers. Their extubation rates were 75 percent, 82 percent and 93 percent, respectively.
“We came to the conclusion that Precedex can lower the stress response with giving us the chance to extubate the patient at the end of the procedure,” Naguib says. “Then came the question: OK, you are able to extubate these kids safely and we have a good protocol. Did we actually protect these kids on the long-term outcome?”
The answer is yes. In a follow-up study that assessed neurodevelopmental outcomes, they found no strong difference with the three treatments. The high-dose group achieved overall higher neurodevelopment scores, although the finding was not statistically significant (Saudi J Anaethesth 2015;9:12-18).
Good surgical and anesthetic techniques during procedures contribute only partially to successful OR extubation. Badhwar and Naguib emphasize the importance of preparation, communication and team work, not only in the OR but in the ICU as well. That includes educating patients and their families and open communication among physicians and staff in the OR and postoperatively.
“It is not just pulling the tube, but it is preparing the patient,” Badhwar says. “If the patients are prepared diligently then they are naturally ready for extubation on the timeline you want them to be.”
Having the patient’s whole healthcare team on board, from prep to discharge, increases the likelihood of a successful OR extubation and excellent outcomes. “To achieve a safe extubation cannot be just a protocol,” Naguib says. “If I can stress anything, it is communication between the anesthesiologist, the surgeon and perfusionist in the OR, and the OR team and the ICU team. That is really important.”