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Ann Thorac Surg 1999;68:1326-1329
© 1999 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Routine immediate extubation after cardiac operation: a review of our first 100 patients

^a Department of Anesthesia, The Royal Melbourne Hospital, Melbourne, Australia
^b Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, Australia

Address reprint requests to Dr Royse, Department of Anesthesia, The Royal Melbourne Hospital, PO Box 1022, Research, Victoria, 3095 Australia
e-mail: colinroyse{at}msn.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Early extubation after cardiac operation is an important aspect of fast-track cardiac anesthesia. Immediate extubation is an extension of this concept. We describe a technique that allows immediate extubation in the majority of patients.

Methods. To allow rapid emergence, anesthesia was modified from a high-dose opioid technique to intravenous propofol anesthesia supplemented with sevoflurane. Normothermic cardiopulmonary bypass was used with routine intermittent antegrade and retrograde tepid blood cardioplegia. High thoracic epidural analgesia was used to facilitate immediate extubation in the majority of patients. Contraindications to immediate extubation were prolonged cardiopulmonary bypass (CPB) (>2.5 hours), hemodynamic instability, uncontrolled bleeding, morbid obesity, severe pulmonary hypertension, congestive cardiac failure, or if the operation was emergent.

Results. Of 109 consecutive patients, 100 were immediately extubated (92%). No patient required reintubation within the first 24 hours after operation. One patient required reintubation 3 days after operation for sputum retention, and 2 patients required reoperation. There was no mortality and the incidence of perioperative morbidity was low.

Conclusions. Immediate extubation after cardiac operation can be safely achieved and is possible in a majority of patients.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Postoperative ventilation of patients undergoing cardiac operation has been standard practice for the past three decades [1]. Initially, it was justified because of a relatively high incidence of respiratory insufficiency or low cardiac output state after cardiac operation, and the almost universal use of a high-dose opioid anesthetic technique [1]. This practice has not changed substantially until the current decade, where economic considerations have been a driving force for fast-track cardiac anesthesia [2, 3].

Early extubation is an essential stage in the fast-track process [4] and, importantly, it is a prerequisite before any changes to intensive care unit (ICU) organization can occur. Many studies have addressed the issue of early extubation and shown that ventilation times can be reduced without increased risk to the patient [2–6]. The question remains whether routine ventilation is absolutely necessary after cardiac operation. Recent advances in anesthesia, surgery, myocardial protection, hemodynamic monitoring, and postoperative analgesia have indeed reduced the need to ventilate patients postoperatively. Immediate extubation, where patients are extubated before leaving the operating room, is a further step in this process.

In this report, we detail our technique that has allowed the majority of patients undergoing cardiac operation to be extubated before leaving the operating room.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
This study is a prospective audit of 109 consecutive patients undergoing cardiac operation, where the anesthetic technique was modified to allow immediate extubation. This anesthetic technique is now part of our routine practice.

The essential aspects to immediate extubation include choice of anesthetic agents, maintenance of normothermia, hemodynamic stability, and postoperative analgesia.

The patients were premedicated with temazepam (20 mg) and acetaminophen (15 mg/kg). They were induced with midazolam (3 to 5 mg), fentanyl (200 µg), a titrated dose of propofol, and rocuronium (50 mg). Maintenance anesthesia consisted of 1% sevoflurane in a 50% oxygen/air mix and a propofol infusion (100 to 400 mg/hr). Muscle relaxants were not used after the first dose unless there was patient movement. This approach was used as an indicator of inadequate anesthesia, which was deepened after additional neuromuscular blockage administration. Maintenance anesthesia was continued during CPB with the volatile agent delivered through the CPB circuit. After weaning from CPB, anesthesia was gradually reduced and terminated after the last skin stitch. Paralysis was not reversed unless recent doses of rocuronium had been administered.

The majority of patients (n = 69) received high thoracic epidural anesthesia in addition to the general anesthesia described. An epidural catheter was inserted at the T2–3 level the night before the operation. The initial dose during operation was 8 to 12 mL of ropivacaine 0.5% with 50 to 100 µg of fentanyl. Contraindications to epidural insertion included preoperative anticoagulation, sepsis, history of spinal damage or operation, and patient refusal. Patients were considered anticoagulated if they had received unfractionated heparin 12 hours before insertion, or low molecular weight heparin within 24 hours or if their international normalized ratio was more than 1.2 after cessation of warfarin. We do not consider recent aspirin ingestion (< 5 days) to be a contraindication to epidural insertion.

Normothermia (core body temperature, 35°C to 37°C) was maintained throughout the surgical procedure. This was achieved by the routine use of warmed fluids, a forced air warmer placed over the legs, and normothermic CPB. The CPB temperature was maintained between 35°C and 36°C and full rewarming to 37°C was achieved before weaning from CPB. Placement of a forced air warmer was possible because lower limb venous harvesting was not performed. Revascularization was achieved by using a composite arterial pedicled Y graft as the routine technique for coronary artery bypass grafting (CABG). The groin is left exposed to allow access to the femoral vessels and the warming blanket placed below this.

Meticulous myocardial protection during CPB is a necessary prerequisite for stable myocardial function after CPB. In particular, we use intermittent antegrade and retrograde cardioplegia, delivering 500 mL of tepid blood cardioplegia (20°C to 30°C), after each anastomosis (5 to 15 minutes). Myocardial reperfusion is established through the pedicled Y graft before removal of the cross-clamp, or through the retrograde cardioplegia cannula for patients undergoing non-CABG. Transesophageal echocardiography is used in all patients and used during CPB for detection of ventricular distention. It allows direct visualization of left ventricular filling, detection of abnormal ventricular function, and detection of ischemia determined by new regional wall motion abnormalities. Transesophageal echocardiography helps identify patients who are unsuitable for immediate or early extubation because of hemodynamic instability.

Two analgesic regimens were used in this series. Patients who did not receive epidural analgesia were given acetaminophen as part of their premedication, and acetaminophen and indomethacin suppositories before extubation. Sternotomy wound and chest tube sites were infiltrated with 20 to 30 mL of 0.75% ropivacaine to a maximum dose of 3 mg/kg. Postoperatively they received a nurse-controlled fentanyl infusion (10 to 100 µg/h). Supplemental analgesia with acetaminophen and indomethacin was given as required. For those receiving epidural anesthesia, a continuous infusion of 0.2% ropivacaine and 2 µg/mL of fentanyl was used to maintain a dermatomal spread of T1–T10. The infusion rate varied from 5 to 15 mL/h. Typically, for small patients (< 50 kg) the infusion would commence at 5 mL/h, average-sized patients at 8 mL/h, and large patients (> 100 kg) at 10 to 12 mL/h. The infusion was continued for 2 to 3 days postoperatively, after which most patients required only oral analgesics.

Patients were not extubated before leaving the theater if there was prolonged cardiopulmonary bypass (> 2.5 hours), hemodynamic instability, morbid obesity, core temperature below 36°C, severe pulmonary hypertension, bleeding requiring platelet or clotting factor transfusion, or where adequate spontaneous ventilation was not achieved by the end of the operation (low tidal volumes; oxygen saturation, < 95%; respiratory rate, > 20 breaths/min; or end-tidal CO₂ tension, > 50 mm Hg). Preoperative contraindications included emergent operation or congestive cardiac failure.

After CPB, minute ventilation was gradually reduced to allow carbon dioxide levels to increase and stimulate respiration. Spontaneous respiration was allowed after closure of the chest. Extubation was then performed after transfer to the patient’s bed and before transfer from the operation room.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
One hundred nine consecutive patients are included in this series. Demographic data are presented in Table 1. One hundred were extubated before leaving the theater (92%), and of these, 69 had epidural analgesia. The reasons for not extubating 9 patients are as follows: prolonged CPB (> 2.5 hours), 4 patients; preoperative pulmonary edema, 2; morbid obesity, 1; obesity and obstructive sleep apnea, 1; and severe pulmonary hypertension, 1 patient. Coronary artery bypass grafting was the most frequent procedure performed. Operation details for extubated patients are as follows: CABG, 80% of patients; CABG and valva replacement/repair, 6%; single valva replacement/repair, 8%; redo CABG, 2%; aortic root replacement, 2%; atrial septal defect closure, 1%; and CABG without use of CPB through the anterolateral thoracotomy approach, 1% of patients.

The mean (confidence intervals) core temperature on arrival to the ICU was 36.6°C (36.5° to 36.7°C) and the skin temperature measured at the foot was 33.5°C (33.2° to 33.8°C). Postoperative shivering occurred in 4 patients, with only one episode of severe shivering recorded.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Immediate extubation after cardiac operations is not a new concept. Many centers around the world use these techniques to a greater or lesser degree [4, 6–9]. Our results show that immediate extubation can be performed safely and in a routine fashion.

The potential benefits of early extubation include cost savings [1], lowered nursing dependency [6], reduced airway and lung trauma [10], improved cardiac output and renal perfusion with spontaneous respiration [11], as well as the reduced stress and discomfort of endotracheal suctioning and weaning from ventilation. Immediate extubation is a further development of fast-track anesthesia. There is additional cost saving because ventilator disposables are avoided, and patients can be transferred to a lower dependency ICU from the operating room. Furthermore, there is no need for sedative drugs.

Opponents to early extubation argue that the immediate perioperative period is the most critical for myocardial ischemia, hemodynamic instability, and sympathetic nervous system activation [12]. The low incidence of perioperative morbidity in this series suggests that our techniques may overcome these limitations. Our mortality (0%) and morbidity data for reintubation, perioperative myocardial infarction, stroke, low cardiac output state, and respiratory complications are low and compare favorably to other series [13–15]. A concern of immediate extubation is the possibility of reintubation and ventilation for respiratory failure in the immediate postoperative period. In this series, no patient required reintubation within 24 hours of the operation. The chances of requiring reintubation will be increased if the patients are hemodynamically unstable, cold, hypovolemic, or requiring considerable opiate medication. The challenge is to deliver a stable, warm, euvolemic, analgesed, and awake patient at the completion of operation. Clearly this is possible in the majority of patients undergoing cardiac operations. In our series of extubated patients, no patients required inotropes to wean from CPB and only 1 patient required inotropes in the postoperative period for low cardiac output state. Shivering is always a potential problem in the postoperative period by causing an increase in myocardial oxygen demand. Our results show that by maintaining normothermia throughout the operation, shivering is an uncommon event.

The modifications to anesthetic technique that enable routine immediate extubation will also enable very early extubation (< 1 hour) in the ICU. Intubated patients can be transferred to the ICU or to a postanesthetic recovery unit breathing spontaneously and extubated shortly after arrival. Sedation can be prolonged by a low-dose propofol infusion (30 to 50 mg/h). The key aspects of our technique are the use of short-duration anesthetic agents, maintenance of normothermia, hemodynamic stability, and optimizing analgesia. These techniques allow extubation at any stage from the end of the operation to some hours later in the ICU. Whether a surgical unit aims for immediate or early extubation will depend on their philosophy, surgical and CPB techniques, and ICU structure. Indeed, it may be preferable for units wishing to adopt these techniques to aim for very early extubation before attempting immediate extubation, because all aspects of our technique must be accomplished to ensure safety. For example, if the patient’s core temperature is less than 36°C at the end of the operation we would advise against immediate extubation. The patient could be transferred to the ICU spontaneously breathing with light sedation and extubated as soon as rewarming is completed.

Epidural analgesia is an important adjunct to immediate extubation because the intraoperative anesthesia requirements are less and analgesia optimized. Patients have little or no pain and no need for intravenous opioid analgesia. Epidurals, however, are not essential for immediate extubation.

The safety of high thoracic epidural anesthesia in cardiac surgery centers depends on whether there is an increased risk of epidural hematoma associated with CPB anticoagulation. This is a rare but serious complication that can result in permanent neurologic damage including paraplegia. It is believed to be more likely if the catheter is inserted or removed while the patient is anticoagulated [9]. One solution is to insert the epidural catheter the night before the operation and remove the catheter after the procedure when coagulation has returned to normal. If an epidural vessel is breached during insertion, there is ample time for the bleeding to stop and the vessel to seal before anticoagulation. This follows the practice of other investigators [8, 9, 16], and to date there have not been reports of paraplegia after epidural use in cardiac operations [16]. By adhering to such guidelines, we believe that the risk of epidural use is essentially the same for cardiac operations as for other types of operations. The risk of paraplegia after epidural use is difficult to determine accurately because it is a rare event. Estimates of neurologic damage range from 0.52:10,000 epidurals and paraplegia rate of 1:170,000 epidurals to 0 neurologic complications after 30,000 epidurals [17–19]. We quote patients a risk of 1:20,000 for permanent neurologic damage. We believe that this is a remote risk given the risk of cardiac operation in general.

Epidural anesthesia may offer benefits in addition to optimal analgesia. Benefits, such as modulation of the stress response [7], improved hemodynamic stability, lower frequency of arrhythmias [8], improved postoperative lung function [7, 20], and a reduction in postoperative myocardial ischemia and infarction [16], have been reported.

We have not attempted to investigate the potential cost saving or reductions in ICU time resulting from this technique. Our unit has a single ICU with no dedicated lower dependency section. Patients are discharged directly to the ward from ICU and this occurs on the first or second postoperative day according to a predetermined protocol. To achieve cost savings from a fast-track approach, the structure of an ICU must change to accommodate both low and high dependency patients [3]. Routine, safe immediate or very early extubation is an important precursor to changes in ICU organization because it follows that these patients will have achieved early return of adequate spontaneous ventilation, are hemodynamically stable, warm, and have adequate analgesia. Cost savings are possible if these patients are transferred directly to a lower dependency ICU where fewer staff are required to manage each patient. Alternatively, if there is little additional cost to a short period of ventilation (such as no additional staff required and minimal use of disposable items), then immediate extubation may not reduce costs, and very early extubation may be a more attractive approach.

In our initial experience of 100 patients, immediate extubation after cardiac operation may be safely achieved in the majority of patients. The use of epidural analgesia offers the additional benefit of optimized postoperative analgesia.

	Acknowledgments

 
We appreciate the support and dedication of the nursing staff, Cardiothoracic Ward, The Royal Melbourne Hospital, and the assistance of Karen Groves in the preparation of this manuscript.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alistair G. Royse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Royse, C. F. Articles by Soeding, P. F. Search for Related Content PubMed PubMed Citation Articles by Royse, C. F. Articles by Soeding, P. F.