Extubation

Created: June 28, 2021

Last Updated: November 18, 2023

Contributor(s):

ERAS Cardiac Collaborative Network

Editor(s):

Alexander Gregory MD FRCPC

Summary

Early extubation after cardiac surgery can offer several benefits, including improved patient comfort, reduced complications, shortened ICU stay, and cost savings. However, it requires a careful and individualized approach to ensure that it is done safely and effectively for each patient.

Early extubation following cardiac surgery refers to the process of removing the endotracheal tube and transitioning the patient from mechanical ventilation to spontaneous breathing in a safe but expedited fashion. Although no formal definition exists, it is generally agreed that early extubation is defined as having occurred in < 6 hours following surgery

There are many potential benefits of early extubation. These include:

Improved Patient Comfort:

  • Early extubation leads to increased patient comfort, as the patient no longer has a tube in their throat, leading to less anxiety and discomfort.

Reduced Ventilator-Associated Complications:

  • Early removal of the endotracheal tube can reduce the risk of complications associated with prolonged mechanical ventilation, such as ventilator-associated pneumonia and lung infections.

Enhanced Pulmonary Function:

  • It encourages spontaneous breathing and coughing, promoting lung expansion and reducing atelectasis and other pulmonary complications.

Shortened ICU Stay:

  • Patients who are extubated early often have shorter ICU stays, leading to more available ICU beds and resources for other critically ill patients.

Cost Reduction:

  • A shorter ICU stay and reduced complications associated with prolonged ventilation contribute to lowered healthcare costs.

Faster Recovery:

  • Early extubation is often associated with a quicker return of cognitive and physical function, leading to enhanced overall recovery.

Successful implementation of an early extubation strategy requires several factors:

Patient Selection:

  • Early extubation is not suitable for every patient. It requires careful patient selection considering the individual's preoperative health status, the complexity of the surgery, and the patient's postoperative stability and pulmonary function.

Multidisciplinary Approach:

  • Successful early extubation requires a team approach, involving physicians, nurses, and respiratory therapists to ensure patient safety and comfort.

Monitoring and Support:

  • Close monitoring is essential to identify any complications early and provide necessary support, including respiratory, hemodynamic, and pain management.

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This summary was written with assistance from artificial intelligence. All text was reviewed, edited, and supplemented by the listed editor(s). Reference: OpenAI. (2023). ChatGPT (Sept 25 version) [Large language model]. https://chat.openai.com/chat

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Educational Materials

Early Extubation: Benefits and Strategies
This video is a recorded session from the ERAS Cardiac Virtual Meeting in 2021. Speakers and discussants include members of our international network of ERAS experts. In this session, participants discuss tips for facilitating early extubation.

References:

  1. Wong WT, Lai VK, Chee YE, et al. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 2016;9(9):CD003587.
  2. Flynn BC, He J, Richey M, Wirtz K, Daon E. Early extubation without Increased Adverse Events in High-Risk Cardiac Surgical Patients. Ann Thorac Surg. 2019 Feb;107(2):453-459.
  3. Brovman EY, Tolis G, Hirji S, Axtell A, Fields K, Muehlschlegel JD, Urman RD, Deseda GAC, Kaneko T, Karamnov S. Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Biinstitutional Study. J Cardiothorac Vasc Anesth. 2021 Nov 27:S1053-0770(21)01031-4.
  4. Gershengorn HB, Wunsch H, Hua M, Bavaria JE, Gutsche J. Association of Overnight Extubation With Outcomes After Cardiac Surgery in the Intensive Care Unit. Ann Thorac Surg. 2019 Aug;108(2):432-442.
  5. Probst S, Cech C, Haentschel D, et al. A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. Crit Care 2014;18(4):468.
  6. Ellis MF, Pena H, Cadavero A, Farrell D, Kettle M, Kaatz AR, Thomas T, Granger B, Ghadimi K. Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol. Crit Care Nurse. 2021 Jun 1;41(3):14-24.
  7. Serena G, Corredor C, Fletcher N, et al. Implementation of a nurse-led protocol for early extubation after cardiac surgery: a pilot study. World J Crit Care Med 2019;8(3):28–35
  8. Chan JL, Miller JG, Murphy M, Greenberg A, Iraola M, Horvath KA.A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery. Ann Thorac Surg. 2018 Jun;105(6):1684-1690.
  9. Grant MC, Isada T, Ruzankin P, Whitman G, Lawton JS, Dodd-O J, Barodka V; Johns Hopkins Enhanced Recovery Program for the Cardiac Surgery Working Group. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg. 2020 Apr;159(4):1393-1402.e7.
  10. Horswell JL, Herbert MA, Prince SL, et. al.: Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients. J Cardiothorac Vasc Anesth 2005; 19: pp. 282-287
  11. Dorsa AG, Rossi AI, Thierer J, et. al.: Immediate extubation after off-pump coronary artery bypass graft surgery in 1,196 consecutive patients: Feasibility, safety and predictors of when not to attempt it. J Cardiothorac Vasc Anesth 2011; 25: pp. 431-436.
  12. Chamchad D, Horrow JC, Nachamchik L, et. al.: The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay. J Cardiothorac Vasc Anesth 2010; 24: pp. 780-784.
  13. Gangopadhyay S, Acharjee A, Nayak SK, et. al.: Immediate extubation versus standard postoperative ventilation: Our experience in on pump open heart surgery. Indian J Anaesth 2010; 54: pp. 525-530.
  14. Sostaric M, Gersak B, Novak-Jankovic V.: Early extubation and fast-track anesthetic technique for endoscopic cardiac surgery. Heart Surg Forum 2010; 13: pp. E190-E194.
  15. Badhwar V, Esper S, Brooks M, Mulukutla S, Hardison R, Mallios D, Chu D, Wei L, Subramaniam K. Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs. J Thorac Cardiovasc Surg. 2014 Dec;148(6):3101-9.e1.
  16. Subramaniam K, DeAndrade DS, Mandell DR, Althouse AD, Manmohan R, Esper SA, Varga JM, Badhwar V. Predictors of operating room extubation in adult cardiac surgery. J Thorac Cardiovasc Surg. 2017 Nov;154(5):1656-1665.e2.
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