Timing of Tracheal Extubation in Adult Cardiac Surgery Patients

Abstract

In this article, we examine 14 studies conducted from 1974 to 1994 on "early" endotracheal extubation (0 to 12 hours postoperatively) in adult cardiac surgery patients. Aspects reviewed include: criteria for patient selection; criteria for extubation; analyses of feasibility and safety; effects of anesthetic technique; and patient morbidity. Advantages and disadvantages of early or "fast-track" extubation are discussed as are directions for future research. Selection criteria varied among studies; patients were most commonly excluded because of severe, preexisting pulmonary disease or ventricular dysfunction. Based on the studies examined, however, at least 70% to 80% of adult patients would meet selection criteria. Three universal criteria were applied in all studies: (1) patient is awake and responsive; (2) adequate gas exchange while breathing spontaneously; and (3) cardiovascular stability. To facilitate early extubation in appropriately selected patients, the choice of anesthetic technique and postoperative sedation technique appears to be important. Anesthetic techniques based on inhalational anesthetic agents, supplemented by moderate doses of narcotics, are more appropriate than high-dose narcotic anesthesia for early extubation protocols. Postoperative sedation with propofol, which has a rapid offset of action, may be particularly advantageous. Every published investigation has concluded that early extubation is safe, feasible, and desirable. Morbidity and mortality have not been shown to be affected by early extubation. Anesthetic technique and the patient's medical condition are the two major factors to consider in accomplishing early extubation.

Evidence‐based practice – an incomplete model of the relationship between theory and professional work

“…The majority of studies are retrospective and do not account for advances in surgical technique, in the management of cardiopulmonary bypass, the introduction of new strategies to reduce bleeding, better intraoperative myocardial protection or anaesthetic strategy (Shapiro & Lichtenthal 1993; Hickey & Carson 1995). This is particularly significant with the recent increase in early extubation and fast tracking in the field of cardiac surgery.…”

“…Traditionally, patients have spent the first 24 hours post‐operatively in an ICU often remaining intubated and ventilated until the first post‐operative morning. There is evidence to support this approach following cardiac surgery with its benefits of decreasing the work of breathing (Keresztes & Kuruzar 1996), as well as providing time both for recovery from the physiological stress of cardiopulmonary bypass (Siliciano 1992) and to return to theatre if complications arise (Hickey & Carson 1995).…”

“…1996), increases in cardiac function and a reduction in respiratory complications (Papadakos & Earley 1995). Karski (1995) identified a reduction in the number of cancellations through the use of the technique and Hickey & Carson (1995) found a reduction in the use of analgesics, hypnotics and muscle relaxant requirements.…”

Patients and surgery-related factors that affect time to recovery of consciousness in adult patients undergoing elective cardiac surgery

“…3 On the other hand, ROC is a major criterion for tracheal extubation after cardiac surgery. 4,5 Therefore, timely awakening to facilitate early assessment of postoperative neurological function and tracheal extubation is of paramount importance among patients undergoing cardiac surgery.…”

Extubación del paciente perioperatorio con una vía aérea difícil

“…Antes de la intubación deben cumplirse los criterios usuales, incluyendo estabilidad hemodinámica, adecuada capacidad de oxigenación, normotermia, frecuencia respiratoria y volumen corriente adecuados, buena saturación de oxígeno y un paciente consciente, alerta, que pueda aclarar las secreciones, proteger la vía aérea y mantener la permeabilidad de la misma (tabla 3) 26,27 . Los pacientes en alto riesgo de extubación fallida son los que pudieran desarrollar hipoventilación, desarreglo de la ventilación/perfusión, fallo de la limpieza pulmonar u obstrucción de la vía aérea.…”