The impact of surgical incision on hospital stay in patients extubated in the operating room after cardiac surgery

Abstract

Central MessageAmong cardiac surgical patients who are extubated in the OR, there was little difference in ICU and hospital stay among patients with minimal access incision versus those with full sternotomy.See Commentaries on pages 65 and 67. Among cardiac surgical patients who are extubated in the OR, there was little difference in ICU and hospital stay among patients with minimal access incision versus those with full sternotomy. See Commentaries on pages 65 and 67. Early extubation is an important component of fast-track recovery protocols that reduce postoperative resource use, and extubation in the operating room (OR) is commonly used in patients who undergo minimally invasive cardiac surgery.1Badhwar 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 It is generally acknowledged that minimal access incisions are associated with reduced length of intensive care unit (ICU) stay and length of stay (LOS) compared with full sternotomy.2Atluri P. Stetson R.L. Hung G. Gaffey A.C. Szeto W.Y. Acker M.A. et al.Minimally invasive mitral valve surgery is associated with equivalent cost and shorter hospital stay when compared with traditional sternotomy.J Thorac Cardiovasc Surg. 2016; 151: 385-388Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar A systematic review and meta-analysis of mitral valve surgery reported shorter LOS with minithoracotomy.3Al Otaibi A. Gupta S. Belley-Cote E.P. Alsagheir A. Spence J. Parry D. et al.Mini-thoracotomy vs. conventional sternotomy mitral valve surgery: a systematic review and meta-analysis.J Cardiovasc Surg (Torino). 2017; 58: 489-496PubMed Google Scholar However, extubation status, the critical first step in an accelerated care pathway, was not addressed in these studies. To better understand the impact of surgical incision on ICU stay and LOS, we reviewed the early outcomes of fast-track patients who were extubated in the OR after cardiac surgery stratified by surgical approach. We identified a consecutive cohort of patients undergoing cardiac surgery who were extubated in the OR between January 1, 2015, and August 31, 2018, at the Mayo Clinic, Rochester, Minnesota. Demographics and surgery-related information were obtained from the departmental and institutional databases, and validated by review of the medical records. The study was approved by the Mayo Foundation Institutional Review Board. All patients gave informed consent for research. Patients were classified into 2 groups based on the surgical incision, full sternotomy, or less-invasive incisions, which include partial upper sternotomy and limited thoracotomies for robotic or port-access approaches. Partial sternotomy refers to upper sternotomy, and minithoracotomy refers to a right- or left-sided intercostal incision of 6.0 cm or less. The primary end points were length of ICU and LOS stays, and early mortality. The secondary end points were operative time, anesthesia time, and discharge location. Descriptive statistics are reported as number (percentage) or median (interquartile range [IQR]) as appropriate. Differences between groups were assessed by chi-square analysis, Fisher exact test, or Wilcoxon rank-sum test as appropriate. During the study period, 104 patients undergoing cardiac surgery were extubated in the OR. Patients' median age was 62.5 years (IQR, 52.3-71.5 years), and 46 (44.2%) were female. There were 44 patients (42.3%) in the full sternotomy group and 60 patients (57.7%) in the less-invasive incision group (13 partial median sternotomies, 40 mini or limited thoracotomies, and 7 port accesses). As shown in Table 1, the less-invasive incision group included more male patients and valve procedures, particularly single valve surgery. Other cardiac surgical procedures, not inc