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Eur J Cardiothorac Surg 2002;21:1026-1030
© 2002 Elsevier Science NL

Early extubation does not increase complication rates after coronary artery bypass graft surgery with cardiopulmonary bypass

J. Reisa*, J.C. Motab, P. Ponceb, A. Costa-Pereirac, M. Guerreirob

a Department of Anesthesiology and Emergency, Centro Hospitalar de Vila Nova de Gaia, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
b Department of Cardiothoracic Surgery, CHVN of Gaia, Vila Nova de Gaia, Portugal
c Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Oporto, Oporto, Portugal

Received 10 August 2001; received in revised form 14 February 2002; accepted 19 February 2002.

* Corresponding author. Tel./fax: +351-22-6092646
e-mail: jreis{at}chvng.min-saude.pt


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: With the evolution of anesthesia and surgical procedures, fast track extubation has gained an increased interest, mainly based on the possibility of reducing health costs seemingly without compromising patient care. Aim: To compare two groups of patients submitted to a non-fast track extubation and a fast track extubation protocol after coronary artery bypass graft surgery with cardiopulmonary bypass, regarding their times of ventilation and intubation and their complication rates in the postoperative period. Methods: During the year of 1998, 323 sequential patients scheduled for isolated coronary artery bypass graft surgery with cardiopulmonary bypass were enrolled in the study. Fifty-nine patients were excluded due to preoperative use of emergent mechanical and/or inotropic hemodynamic support, low body mass index (<=18–20 kg/m2), reoperations for acute surgical complications, off-pump coronary artery bypass graft surgery, severe respiratory disease, recent myocardial infarction (<=7 days) and absence of relevant data. Previous myocardial infarction (>=7 days), prophylactic intraaortic balloon pump and use of postoperative vasoactive drugs were not exclusion criteria. We compared 76 patients sequentially submitted to anesthesia by one of the authors with a fast track extubation protocol and 188 patients sequentially submitted to anesthesia by others in the same period and using a conventional anesthetic protocol. Results: Demographic data, previous medical and cardiac history, preoperative medication and operative data were all similar between the two groups. The mean ventilation and intubation times were significantly shorter in the fast track extubation group than in the non-fast track extubation patients (30 min vs. 7 h and 50 min vs. 8 h, respectively). Forty-two percent of patients in the fast track extubation group were extubated on arrival at the intensive care unit. Morbidity and mortality were similar in both groups. Conclusions: The study shows that a very fast track extubation protocol may be safely implemented in patients submitted to coronary artery bypass graft surgery with cardiopulmonary bypass.

Key Words: Coronary artery bypass graft surgery • Fast track extubation • Postoperative complications


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Advances in anesthesia [1] and surgery, extracorporeal perfusion techniques and perioperative care medicine have been crucial in improving postoperative outcome but the risk for respiratory complications after cardiac surgery remains high, mainly due to the thoracic surgical approach, complications of tracheal entubation [2,3] and mechanical ventilation [4–7] and other associated risk factors such as age [8].

In cardiac surgery, prolonged controlled ventilation has been a standard practice, mainly because of high-dose narcotic anesthesia and fear of myocardial ischemia [9] in the early postoperative period. However, fast track extubation (FTE) protocols are becoming increasingly popular [10–13] mainly due to a greater rationalization of resource utilization [14,15].

In the last years, published data have shown that early extubation (less than 8 h) after cardiac surgery is well documented [14], and may be effective [13] and cost-effective [15,16]. Lower costs in the postoperative period, mainly due to a reduction in intensive care (ICU) and hospital length of stay (LOS), could also be achieved [13,17]. However, different times for early extubation have been used depending on the author's own protocols and experiences and some lack of information or controversy still remains regarding the safety of a very early or immediate extubation just after surgery.

In this study, the authors intend to analyze the possible consequences on morbidity and mortality of a very early extubation protocol among patients submitted to coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB).


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
During the year of 1998, all 323 sequential patients submitted to CABG surgery with CPB were enrolled in the study. From those 59 were excluded due to the criteria presented in Table 1. Previous myocardial infarction (>=7 days), prophylactic intraaortic balloon pump (IABP) and use of postoperative vasoactive drugs were not exclusion criteria. Providing these selection criteria were met, the allocation of patients per group was done prior to surgery and according to the scheduled anesthesiologist: FTE group if one of the authors was involved; non-fast track extubation (NFTE) group if any other anesthesiologist was involved. The scheduling of anesthesiologists was done in a random way by someone not involved in the study.


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  		Table 1. Exclusion criteria and numbers of patients excluded according to fast track (FTE) (n=92) and non-fast track extubation (NFTE) (n=231) groupsa

 
In this manner, retrospective data from 76 patients using an FTE protocol were compared with data from 188 patients in the NFTE group anesthetized, in the same period, using a conventional protocol.

The anesthetic technique in the FTE group included: premedication with oral lorazepan; induction with fentanyl 0.0075–0.01 mg/kg and propofol 0.4–1.0 mg/kg (2–5 mg/kg per h on CPB); maintenance with isoflurane; and patient controlled analgesia (PCA)-morphine for postoperative pain control. In contrast, in the NFTE group it included: premedication, in some patients, including besides oral lorazepan, morphine and scopolamine; induction with propofol or etomidate; maintenance with sevoflurane; and i.v. morphine in the postoperative period for pain control.

Extubation criteria were: patient awake, calm and cooperative, mediastinal drainage less than 75–100 ml in the last half hour, negative inspiratory force (NIF) >17–20 cm H2O, respiratory rate (RR) <30 cc/min, PaCO2 <50 mmHg (except chronic obstructive pulmonary disease (COPD) patients), and PaO2 >70 mmHg with FiO2 <0.5 if possible.

Statistical analysis was performed with Student's t-test and {chi}2 as appropriate. A P value of <0.05 was considered statistically significant. Continuous data are expressed as means (standard deviations), and categorical data as counts and percentages.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
3.1. Preoperative and operative data
Table 2 shows demographic, medical and cardiac history and operative data. The patient's demographic and biological characteristics were similar in both groups. There were no significant differences in gender, age, body mass index (BMI) or number of bypass grafts performed between FTE and NFTE groups. The duration of CPB and aortic cross clamp (AXC) were also similar in both groups.


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  		Table 2. Comparison of demographic data, preoperative medication, previous medical and cardiac history and operative data between fast track (FTE) (n=76) and non-fast track extubation (NFTE) (n=188) patientsa

 
3.2. Outcome data
There was no significant difference in the mean mediastinal drainage or hospital LOS between FTE and NFTE groups (Table 3). Only 45% of the patients in the FTE group required mechanical ventilation compared to nearly all in the NFTE group (P<0.001). Also, 42% of patients in the FTE group were successfully extubated on ICU arrival compared with only 2% among NFTE patients (P<0.001). As shown in Table 4 complications were similar in both groups.


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  		Table 3. Comparison of the postoperative variables between fast track (FTE) (n=76) and non-fast track extubation (NFTE) (n=188) patients

 

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  		Table 4. Comparison of the patient's complication variables between fast track (FTE) (n=76) and non-fast track extubation (NFTE) (n=188) patients

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
In 1986 Millic-Emili [18] suggested that the weaning process was more an art than a science. Over the last years, multiple attempts have been made to measure the importance of matching ventilatory capacity and technological developments with multiple physiopathological syndromes (respiratory ‘patients' needs’). Demling et al. [19] reported in patients undergoing elective cardiothoracic surgery a weaning failure rate of less than 5%. Still, the weaning process in cardiac patients can influence morbidity, mortality and costs.

Multiple factors can influence postoperative ventilation and intubation times. In our study group, we extubated the patients immediately after criteria were achieved (conscious, normothermic, non-bleeding, hemodynamic stable, and with acceptable respiratory function). The lower intubation and ventilation times were due to global strategies in patient management: use of propofol [12,15,20] on induction and during CPB, isoflurane as a major anesthetic, and close control of hemodilution. Postoperative monitoring, control of weaning from mechanical ventilation and criterious endotracheal extubation were also crucial for FT success.

With the FTE group we routinely used isoflurane. The inhalation-based anesthetic technique is an important factor in achieving early extubation [21], and may be an important factor in preventing ischemia-reperfusion injury [22] without coronary steel [19,23]. Oguchi et al. [23] when comparing the effects of potent anesthetic halogenated on metabolic function in isolated rat hearts found greater post-ischemic adenosine triphosphate (ATP) levels in isoflurane and enflurane groups at 1.0 MAC (minimum alveolar concentration)—with a greater preservation of myocardial energy stores, which could lead to a better hemodynamic recovery.

ICU LOS and pain evaluation were not assessed in our study. However, fast track protocols were already shown to reduce ICU LOS [16] and clinical observations have shown us that patients in the FTE group were quite comfortable in the postoperative period with a PCA/NCA-morphine sulfate infusion during the first 24 h after surgery. This protocol contributed to early mobilization and feeding, increasing the patient's autonomy. In addition, fast extubation protocols by reducing the time of mechanical ventilation may also reduce medical and nursing postoperative workload.

Apart from new developments in anesthesia [1] and surgery, anesthetic management is probably the most important factor leading to the success of the fast track pathway, also allowing for better control of contaminant items and influencing the anesthetist risk factor [24,25]. And as in other medial areas, we think that this FTE patient management requires an important learning curve.

In conclusion, we have found that a very early extubation protocol (on average less than 1 h) can be both effective and safe as it reduces intubation and ventilation times without increasing postoperative complications. As early extubation was also shown to be cost-effective (as discussed in Section 1), our data may support a wider use of very fast track extubation protocols in patients submitted for CABG surgery with CPB.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

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