Patients should be extubated in the operating room after routine cardiac surgery: An inconvenient truth

Abstract

Central MessageExtubation in the operating room after routine cardiac surgery is safe and beneficial when facilitated by an aligned multidisciplinary team. Extubation in the operating room after routine cardiac surgery is safe and beneficial when facilitated by an aligned multidisciplinary team. Feature Editor's Introduction—Although 24-hour ventilator times have remained the quality metric for Society for Thoracic Surgeons (STS) Star rankings, it has become apparent over the past several years that the association between vent time and morbidity occurs much earlier.1Crawford T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The reporting of a 6-hour metric for the past 20 years in the STS Adult Cardiac Surgery Database (ACSD) was a recognition of its benefits2Cheng D.C. 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: 1300-1310Crossref PubMed Scopus (334) Google Scholar and pushed us to earlier extubations, such that ventilation time <6 hours has doubled since 2005, currently being accomplished in >60% of isolated coronary artery bypass grafting (CABG) surgeries (2017-20 ACSD Report).In this month's JTCVS Techniques, Hayanga and colleagues3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar in their expert opinion are now challenging us to improve the quality of care we give our patients by raising the bar even higher to extubate patients before leaving the operating room, an event that currently occurs in fewer than 1 in 20 recipients of isolated CABG, for example (2017-20 ACSD Report).Their opinion that this will be better for our patients stands to reason, as this group has championed operating room (OR) extubations for almost a decade, and they substantiate their prejudice by citing their own experience. The authors point out that their propensity-matched study comparing OR extubations to early intensive care unit (ICU) extubations showed significant decreases in ICU length of stay (3 hours) and postoperative length of stay (1 day), and a cost savings of $8 this should read $800 to $900 per patient. However, this expert opinion, which rests so heavily on this one study, might not sufficiently stress its limitations—that it suffers from being observational, retrospective, single-institutional, and clearly open to the criticism that variables not included in the multivariate analysis could have changed the results. Nevertheless, any of us in programs that perform OR extubations realize that it is applicable to far more than 5% of cardiac patients.I am struck by 3 themes within this opinion piece that I find of particular importance. First, OR extubation in the appropriate patient is safe, and possibly beneficial. Second, the authors' emphasis on the multidisciplinary effort to accomplish the task should be lost on no one. The necessity to work together as a team of surgeons, anesthesiologists, perfusionists, and other, is appropriately highlighted. Finally, as the evidence continues to build that OR extubation in the right patient is an improvement in care, the authors challenge all of us to do more of it and lay out the tenets required to do so, safely. They should be commended. As we have done in the past (eg, with mitral valve repair), multiarterial grafting, transcatheter aortic valve replacements, and now, as trumpeted in this article, OR extubations, cardiac surgery should embrace every effort to improve what we do, regar