Breathing Easy Using Extubation in the OR

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UPMC-Cardiac-Surgery-04.jpg - Extubate
From left, surgeon Vinay Badhwar, MD, anesthesiology resident Douglas Bentley, MD, and cardiac surgical operating room nurse Robert Nagel, RN, extubate a patient in the operating room after a mitral valve repair.
Source: John Caldwell, MD

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