Abstract

Introduction: Fast track (FT) cardiac surgery and early extubation (EE) are aimed at safe and effective rapid post-operative progression to discharge, and have been practiced for more than two decades. Their goal is to optimize patient care perioperatively in order to decrease costs without negatively affecting morbidity and mortality. However, the factors that predict successful EE are poorly understood, and patients with significant co-morbidities are frequently excluded from protocols. We hypothesize that independent of disease severity, early extubation leads to shorter hospital stays and can be performed safely without negatively affecting outcomes. Materials and Methods: We performed a retrospective review of 919 patients who underwent coronary artery bypass grafting (CABG) at the Southern Arizona Veteran’s Affairs Health Care System medical center over 7 years. We collected pre-operative data regarding patients’ NYHA classification, presence and severity of cerebral vascular disease, peripheral vascular disease, pulmonary disease, diabetes and hypertension. Intra-operative variables were also recorded including ASA scores, ischemic times, and time to extubation. Finally, post-operative variables such as rates of reintubation and tracheotomy, and both length of ICU and total hospital stay were also compared. Results: Prolonged periods of ischemia were found to predict a delayed extubation (HR = 0.992; CI = 0.988 - 0.997, p = 0.0015) while small body surface area (HR = 1.57; CI = 1.13, 2.17, p = 0.007) and higher pre-operative functional status of the patient, such as independent versus dependent status (HR =1.68; CI = 1.30 - 2.16, p < 0.0001), or partially dependent to fully dependent status (HR = 1.33; CI = 1.03 - 1.70, p = 0.03) were found to be associated with earlier extubation. The early extubation (EE) group (those extubated in less than the median 7.3 hours) had an average hospital stay of 5.1 ± 4.0 days, versus 7.8 ± 8.1 days in the delayed group (>4 hours), p < 0.0001. The EE group also experienced shorter ICU stays by about 1 day (EE, 1.9 ± 4.2 v. conventional, 3.8 ± 17.3, p = 0.02). There were no differences in rates of tracheotomy or re-intubation between groups. Conclusions: In our study population, pre-operative functional class and total body surface area predicted those patients able to tolerate early extubation after cardiac surgery. Prolonged ischemia resulted in delayed extubation. Patients that were extubated in less than 4 hours had shorter ICU and hospitalization stays, while there was no significant difference between the two groups in rate of reintubation or tracheotomy.

Keywords

Coronary Artery Bypass; Fast Track; Early Extubation; Postoperative Period; Intensive Care; Intubation; Treatment Outcome; Airway Extubation

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Conflicts of Interest

The authors declare no conflicts of interest.

References