Early Extubation Without Increased Adverse Events in High-Risk Cardiac Surgical Patients

Background. Previous reports of early extubation after cardiac surgical procedures vary in the definition of "early" and may limit findings to patients with less preoperative risk. This study sought to determine whether an eight-tier multidisciplinary early extubation protocol with the goal of extubating within 6 hours postoperatively would be successful without increasing adverse events in patients with increased preoperative risk. Methods. Postoperative adult cardiac surgical patients in a tertiary care intensive care unit (n = 459) were analyzed 6 months before and 6 months after implementation of the protocol. The Society of Thoracic Surgeons (STS) risk scores were used as surrogate markers of risk. Patients with STS scores (n = 333) were stratified into four equal groups from lowest to highest score. A composite of acute renal failure, reintubation, stroke, and mortality was the primary outcome. Secondary outcomes included intensive care unit and hospital lengths of stay, reoperation, and sternal wound infection. Results. In all patients, ventilation times were significantly decreased from a median of 7.4 hours to 5.7 hours after protocol implementation. When stratified by STS scores, higher-risk patients (groups 3 and 4) had the largest reduction in ventilation times from a median of 9.2 hours to 5.7 hours (p < 0.0001) without a significant increase in adverse events. The highest-risk patients (STS score >40%; n = 14) all had extubation times shorter than 6 hours after the protocol with no significant increase found in adverse events (p = 0.138). Conclusions. A prudent and diligent multifaceted early extubation protocol may be successful in high-risk cardiac surgical patients without an increase in adverse outcomes. A larger study is needed in the future to confirm the finding. (C) 2019 by The Society of Thoracic Surgeons