Early Extubation: A Proposed New Metric

Todd C. Crawford, Jonathan Trent Magruder, Joshua C. Grimm, Christopher Sciortino, John V. Conte, Bo Soo Kim, Robert Higgins, Duke E. Cameron, Marc S Sussman, Glenn Whitman

Research output: Contribution to journalArticle

Abstract

Shorter intubation periods after cardiac surgery are associated with decreased morbidity and mortality. Although the Society of Thoracic Surgeons uses a 6-hour benchmark for early extubation, the time threshold above which complications increase is unknown. Using an institutional Society of Thoracic Surgeons database, we identified 3007 adult patients who underwent 1 of 7 index cardiac operations from 2010-2014. Patients were stratified by the duration of time to extubation after surgery-0-6, 6-9, 9-12, and 12-18 hours. Aggregate outcomes were compared among time-to-extubation cohorts. Primary outcomes included operative mortality and a composite of major postoperative complications; secondary outcomes included prolonged postoperative hospital length of stay (PLOS) (> 14 days) and reintubation. Multivariable logistic regression analysis was used to control for case mix. In results, extubation percentages in each time cohort were hours 0-6-36.4%, 6-9-25.6%, 9-12-12.5%, and 12-18-10.5%. Patients extubated in hours 12-18 vs <12 experienced a significantly higher risk of operative mortality (odds ratio = 2.7, 95% CI: 1.0-7.5, P = 0.05) and the composite complication outcome (odds ratio = 3.6, 95% CI: 2.2-6.1, P <0.01); however, insignificant differences were observed in those extubated in hours 6-9 vs 0-6 nor in hours 9-12 vs 0-9. An identical trend was observed for our secondary outcomes of PLOS and reintubation. In conclusion, our results indicate that the risks of operative mortality, major morbidity, and PLOS do not significantly increase until the time interval to extubation exceeds 12 hours. Cardiac surgery programs should be evaluated on their ability to extubate patients within this time interval.

Original languageEnglish (US)
JournalSeminars in Thoracic and Cardiovascular Surgery
DOIs
StateAccepted/In press - 2016

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Length of Stay
Mortality
Thoracic Surgery
Odds Ratio
Morbidity
Benchmarking
Diagnosis-Related Groups
Intubation
Logistic Models
Regression Analysis
Databases

Keywords

  • Mechanical ventilation
  • Multivariable logistic regression
  • Multivariable logistic regression
  • Operative mortality
  • Society of Thoracic Surgeons
  • Ventilation time

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Early Extubation : A Proposed New Metric. / Crawford, Todd C.; Magruder, Jonathan Trent; Grimm, Joshua C.; Sciortino, Christopher; Conte, John V.; Kim, Bo Soo; Higgins, Robert; Cameron, Duke E.; Sussman, Marc S; Whitman, Glenn.

In: Seminars in Thoracic and Cardiovascular Surgery, 2016.

Research output: Contribution to journalArticle

Crawford, Todd C. ; Magruder, Jonathan Trent ; Grimm, Joshua C. ; Sciortino, Christopher ; Conte, John V. ; Kim, Bo Soo ; Higgins, Robert ; Cameron, Duke E. ; Sussman, Marc S ; Whitman, Glenn. / Early Extubation : A Proposed New Metric. In: Seminars in Thoracic and Cardiovascular Surgery. 2016.
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abstract = "Shorter intubation periods after cardiac surgery are associated with decreased morbidity and mortality. Although the Society of Thoracic Surgeons uses a 6-hour benchmark for early extubation, the time threshold above which complications increase is unknown. Using an institutional Society of Thoracic Surgeons database, we identified 3007 adult patients who underwent 1 of 7 index cardiac operations from 2010-2014. Patients were stratified by the duration of time to extubation after surgery-0-6, 6-9, 9-12, and 12-18 hours. Aggregate outcomes were compared among time-to-extubation cohorts. Primary outcomes included operative mortality and a composite of major postoperative complications; secondary outcomes included prolonged postoperative hospital length of stay (PLOS) (> 14 days) and reintubation. Multivariable logistic regression analysis was used to control for case mix. In results, extubation percentages in each time cohort were hours 0-6-36.4{\%}, 6-9-25.6{\%}, 9-12-12.5{\%}, and 12-18-10.5{\%}. Patients extubated in hours 12-18 vs <12 experienced a significantly higher risk of operative mortality (odds ratio = 2.7, 95{\%} CI: 1.0-7.5, P = 0.05) and the composite complication outcome (odds ratio = 3.6, 95{\%} CI: 2.2-6.1, P <0.01); however, insignificant differences were observed in those extubated in hours 6-9 vs 0-6 nor in hours 9-12 vs 0-9. An identical trend was observed for our secondary outcomes of PLOS and reintubation. In conclusion, our results indicate that the risks of operative mortality, major morbidity, and PLOS do not significantly increase until the time interval to extubation exceeds 12 hours. Cardiac surgery programs should be evaluated on their ability to extubate patients within this time interval.",
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AU - Crawford, Todd C.

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AU - Grimm, Joshua C.

AU - Sciortino, Christopher

AU - Conte, John V.

AU - Kim, Bo Soo

AU - Higgins, Robert

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AU - Sussman, Marc S

AU - Whitman, Glenn

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AB - Shorter intubation periods after cardiac surgery are associated with decreased morbidity and mortality. Although the Society of Thoracic Surgeons uses a 6-hour benchmark for early extubation, the time threshold above which complications increase is unknown. Using an institutional Society of Thoracic Surgeons database, we identified 3007 adult patients who underwent 1 of 7 index cardiac operations from 2010-2014. Patients were stratified by the duration of time to extubation after surgery-0-6, 6-9, 9-12, and 12-18 hours. Aggregate outcomes were compared among time-to-extubation cohorts. Primary outcomes included operative mortality and a composite of major postoperative complications; secondary outcomes included prolonged postoperative hospital length of stay (PLOS) (> 14 days) and reintubation. Multivariable logistic regression analysis was used to control for case mix. In results, extubation percentages in each time cohort were hours 0-6-36.4%, 6-9-25.6%, 9-12-12.5%, and 12-18-10.5%. Patients extubated in hours 12-18 vs <12 experienced a significantly higher risk of operative mortality (odds ratio = 2.7, 95% CI: 1.0-7.5, P = 0.05) and the composite complication outcome (odds ratio = 3.6, 95% CI: 2.2-6.1, P <0.01); however, insignificant differences were observed in those extubated in hours 6-9 vs 0-6 nor in hours 9-12 vs 0-9. An identical trend was observed for our secondary outcomes of PLOS and reintubation. In conclusion, our results indicate that the risks of operative mortality, major morbidity, and PLOS do not significantly increase until the time interval to extubation exceeds 12 hours. Cardiac surgery programs should be evaluated on their ability to extubate patients within this time interval.

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KW - Ventilation time

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