Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery

Analgesic Effect and Sleep Quality of Low-Dose Dexmedetomidine in Cardiac Surgical Patients After Ultrafast-Track Extubation: A Randomized Clinical Trial

OBJECTIVE

To compare the analgesic and sleep quality effects of dexmedetomidine infusion versus placebo in patients undergoing cardiac surgery with ultra-fast track extubation.

DESIGN

The randomized, double-blind clinical trial study.

SETTING

At a single academic center hospital.

PARTICIPANTS

We included patients aged 25 to 65 scheduled for elective cardiac surgery under general anesthesia with cardiopulmonary bypass from October 2021 to December 2022.

INTERVENTION

After immediate extubation in the operating room, the patients who were allocated at first after providing their consent to either the dexmedetomidine group (Dex) or the placebo group (Placebo) received continuous infusion of dexmedetomidine (0.2 μg/kg/h) or saline for 12 hours postoperatively.

MEASUREMENTS AND MAIN RESULTS

The groups' demographic and perioperative variables were not statistically significant. Total morphine consumption in milligrams at 12 and 24 hours after administered study drug, total sleep time in hours by BIS value ≤85, and sleep quality with the Richard-Campbell Sleep Questionnaire were compared. The analysis included 22 Dex and 23 Placebo patients. The consumption of morphine was not statistically different between the Dex and Placebo groups at 12 and 24 hours (p = 0.707 and p = 0.502, respectively). The Dex group had significantly longer sleep time (8.7 h [7.8, 9.5]) than the Placebo group (5.8 h [2.9, 8.5]; p = 0.007). The Dex group also exhibited better sleep quality (7.9 [6.7, 8.7] vs 6.6 [5.2, 8.0]; p = 0.038).

CONCLUSIONS

Sedation with low-dose dexmedetomidine infusion for ultra-fast track extubation following cardiac surgery enhances sleep duration and quality.

Operating Room Extubation for Patients Undergoing Cardiac Surgery: A National Society of Thoracic Surgeons Database Analysis

BACKGROUND

The utility of operating room extubation (ORE) after cardiac surgery over fast-track extubation (FTE) within 6 hours remains contested. We hypothesized ORE would be associated with equivalent rates of morbidity and mortality, relative to FTE.

METHODS

Patients undergoing nonemergent cardiac surgery were identified in The Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2017 and December 2022. Only procedures with The Society of Thoracic Surgeons risk models were included. Risk-adjusted outcomes of ORE and FTE were compared by observed-to-expected ratios with 95% CIs aggregated over all procedure types, and ORE vs FTE adjusted odds ratios (ORs) specific to each procedure type using multivariable logistic regression. Analyzed outcomes were operative mortality, prolonged length of stay, composite reoperation for bleeding and reintubation, and composite morbidity and mortality.

RESULTS

The study population of 669,099 patients across 1069 hospitals included 36,298 ORE patients in 296 hospitals. Risk-adjusted analyses found that ORE was associated with statistically similar or better results across each of the 4 outcomes and procedure subtypes. Notably, rates of postoperative mortality were significantly lower in ORE patients undergoing coronary artery bypass grafting (OR, 0.54; 95% CI, 0.46-0.65), aortic valve replacement (OR, 0.43; 95% CI, 0.24-0.77), and mitral valve replacement (OR, 0.48; 95% CI, 0.26-0.89).

CONCLUSIONS

Extubation in the OR was safe and effective in a selected patient population and may be associated with superior outcomes in coronary artery bypass, aortic valve replacement, and mitral valve replacement. These national data appear to confirm institutional experiences regarding the potential benefit of OR extubation. Further refinement of optimal populations may justify randomized investigation.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes

OBJECTIVES

Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults.

MATERIAL AND METHODS

Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation.

RESULTS

Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment.

CONCLUSIONS

A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.

Minimally invasive cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Minimally invasive (MI) cardiac surgery was introduced to reduce problems associated with a full sternotomy. This meta-analysis aimed to investigate the effects of minimally invasive cardiac surgery on a range of clinical outcomes.

METHODS

To identify potential studies (randomised/prospective clinical trials) systematic searches were carried out. The search strategy included the concepts of "minimally invasive" OR "MIDCAB" AND "coronary artery bypass grafting" OR "cardiac surgery". This was followed by a meta-analysis investigating cross-clamp time, cardiopulmonary bypass (CPB) time, operation time, ventilation time, intensive care unit (ICU) stay, hospital stay, incidence of myocardial infarction and of stroke/neurologic complications.

RESULTS

Eight studies (9 intervention groups), totalling 596 participants were analysed. MI cardiac surgery was associated with a shorter ICU stay mean difference (MD) -0.7days (95% confidence interval (CI) -1.23 to -0.18, p=0.009) and longer cross-clamp MD 6.7min (95% CI 1.24 to 12.17, p=0.02), CPB MD 26.68min (95% CI 10.31 to 43.05, p=0.001), and operation times MD 55.03min (95% CI 22.76 to 87.31, p=0.0008). However no differences were found in the ventilation time MD -3.94h (95% CI -8.09 to 0.21, p=0.06), length of hospital stay MD -1.14days (95% CI -3.11 to 0.83, p=0.26) and in the incidence of myocardial infarction odds ratio (OR) 1.97 (95% CI 0.49 to 7.9, p=0.34) or stroke/neurologic complications OR 0.67 (95% CI 0.11 to 4.05, p=0.66).

CONCLUSIONS

Minimally invasive cardiac surgery is as safe as conventional surgery and could reduce costs due to a shorter period spent in ICU.