Enhanced recovery in cardiac surgery (ERCS) should be the standard postoperative management for most patients. This approach should be seen as multimodal and multidisciplinary, where each participant can contribute minor benefits that cumulatively reduce morbidity and shorten postoperative stays. One of the key factors is patient extubation, marking hemodynamic stability, neurological integrity, respiratory sufficiency, and hemostatic control, essentially signaling the patient’s awakening—a crucial milestone in recovery.

Intubation duration varies depending on patient complexity, institutional practices, and the surgical procedure, resulting in notable differences across studies. Prolonged ventilation solely for monitoring, when extubation criteria are met, is highly detrimental and should be avoided. However, to what extent could intubation be prolonged without adversely affecting the postoperative course? Some authors advocate for OR extubation, with times trending toward zero, while others define early extubation within 2-4 hours post-surgery.

This study examined postoperative outcomes from 2017 to 2022 in myocardial revascularization patients extubated in either the OR or ICU based on protocol. Among 1397 patients, 506 were extubated in the OR and 891 in the ICU. Over 95% of surgeries used cardiopulmonary bypass (CPB), with an average graft count exceeding 3.5. This retrospective, non-randomized study selected patients for extubation based on anesthetist and surgeon consensus, with mandatory criteria: elective surgery, stable intraoperative hemodynamics, no inotropic or mechanical circulatory support, and adequate hemostatic control. Perioperative variables allowed for 414 matched pairs through propensity analysis.

This group’s outcomes were remarkably favorable, with zero mortality and reintubation rates of 1.7% in both groups. Other morbidity rates were similarly low, including stroke (0.5% in both), reoperation for bleeding (0.7% vs. 1.7%, p = 0.2), and postoperative renal failure (0.2%-0.5%). Patient selection yielded a low-risk cohort: average age of 64-65 years, BMI of 27-28 kg/m², STS risk score of 0.8%, and left ventricular ejection fraction of 60%. Surgical times were within normal standards, with an average ischemic time of 90 minutes and CPB time of 110 minutes.

OR extubation was associated with shorter ICU stays (14 vs. 20 hours, p < 0.0001) and postoperative hospital stays (3 vs. 5 days, p < 0.0001), as well as a higher discharge-to-home rate (97.3% vs. 89.9%, p < 0.0001). Prolonged mechanical ventilation, defined as exceeding 24 hours postoperatively, occurred in 1% of OR-extubated versus 3.6% of ICU-extubated patients (p = 0.0106).

The authors conclude that routine OR extubation is feasible and safe for myocardial revascularization surgery patients, without increased morbidity or mortality.

COMMENTARY:

The results presented by this group for myocardial revascularization, one of the most frequently performed and lowest-morbidity cardiac surgeries, are nearly optimal in terms of postoperative morbidity and mortality. However, the profile of this highly selected cohort, typical of the American healthcare system, may not align with public, universal systems like ours. Furthermore, the authors’ generalization of their conclusions is overly optimistic, asserting systematic OR extubation feasibility. The study reflects a retrospective experience over five years, with OR extubation increasing from 6.2% to 83.3%, lacking procedural uniformity. The group’s growing familiarity with this practice introduces bias, alongside the non-randomized design. The selected OR-extubated patients likely had favorable characteristics, leading to superior outcomes. Although propensity adjustments were made, some confounding factors remain challenging to balance adequately.

Despite these considerations, this study offers valuable insights. The described postoperative rehabilitation protocol, including transition through care levels on a timed basis, is exemplary: mobilizing patients within three hours of ICU admission, ambulation within 3-6 hours, and prompt removal of intravenous lines and thoracic drains. Following criteria fulfillment, patients transfer from ICU to intermediate care, resulting in ICU stays averaging less than one day—aligned with the definition of early extubation (within six hours). Postoperative stay differences could stem from a higher postoperative atrial fibrillation rate in the ICU-extubated group (15% vs. 5.1%, p < 0.0001), likely due to uncontrolled confounders rather than direct causation by earlier extubation.

Ultimately, OR extubation is indeed feasible, but with the caveat that candidate selection is likely more restrictive than suggested by the study. Systematizing this approach faces two obstacles: extubation should not substitute appropriate ICU protocols to prevent unnecessary prolonged ventilation, and patient comfort and management should not be compromised by premature extubation without prior postoperative assessment. Thus, the most suitable strategy may be early extubation within a 2-4-hour window post-surgery. While early awakening is pivotal, reaching home discharge remains the ultimate goal, requiring an intensified rehabilitation and daily care protocol to yield substantial benefit.

REFERENCE:

James L, Smith DE, Galloway AC, Paone D, Allison M, Shrivastava S, et al. Routine Extubation in the Operating Room After Isolated Coronary Artery Bypass. Ann Thorac Surg. 2024 Jan;117(1):87-94. doi: 10.1016/j.athoracsur.2023.09.031.