Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial.
BACKGROUND
We undertook a prospective, randomized, controlled clinical trial to evaluate morbidity outcomes and safety of a modified anesthetic technique to provide shorter sedation and early extubation (1 to 6 hours) than those of the conventional anesthetic protocol used for prolonged sedation and extubation (12 to 22 hours) in patients after coronary artery bypass grafting.


METHODS
One hundred twenty patients undergoing elective coronary artery bypass grafting were prospectively assigned randomly to either an early extubation group (n = 60; 15 micrograms.kg-1 fentanyl and 2 to 6 mg.kg-1.hour-1 propofol and isoflurane) or to a conventional extubation group (n = 60; 50 micrograms.kg-1 fentanyl and 0.1 mg.kg-1 midazolam and isoflurane). Cardiac morbidity (postoperative myocardial ischemia, postoperative myocardial infarction, and perioperative sympathoadrenal stress response), respiratory morbidity (postextubation apnea, alveolar-arterial oxygen gradient, pulmonary shunting, oxygen consumption, atelectasis, and reintubation), hemodynamic values and vasoactive medication requirements, intraoperative awareness, postoperative cognitive function, 30 day mortality, and intensive care unit and hospital lengths of stay were compared between the two groups.


RESULTS
Fifty-one of the 60 patients in each group (85%) were extubated within the defined time period. Postoperative extubation time and intensive care unit and hospital lengths of stay were significantly shorter in the early group. At 48 hours after operation, there were no significant differences between the two groups in myocardial ischemia incidences, ischemia burdens, or creatine kinase isoenzyme MB levels. Four patients in the conventional group, but not in the early group, had postoperative myocardial infaction. The extubation anesthetics used were effective in suppressing the perioperative plasma catecholamine stress response in both groups. Postextubation apnea characteristics were similar between the groups. Intrapulmonary shunt fraction improved significantly in the early group at 4 hours after extubation. The incidences and degree of atelectasis did not differ significantly between the two groups. The incidences of treated postoperative complications were comparable between the two groups, but three patients in the conventional group died as a result of stroke or postoperative myocardial infarction.


CONCLUSIONS
Early extubation after coronary artery bypass grafting is safe and does not increase perioperative morbidity. There is an improvement in postextubation intrapulmonary shunt fraction and a reduction in intensive care unit and hospital lengths of stay.
Cheng
D C
DC
Department of Anaesthesia, Toronto Hospital, University of Toronto, Ontario, Canada.
Karski
J
J
Peniston
C
C
Asokumar
B
B
Raveendran
G
G
Carroll
J
J
Nierenberg
H
H
Roger
S
S
Mickle
D
D
Tong
J
J
Zelovitsky
J
J
David
T
T
Sandler
A
A
D000368:Aged; D000768:Anesthesia, General; D018685:Anesthetics, Inhalation / Q000008:administration & dosage; D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D001049:Apnea / Q000209:etiology; D002395:Catecholamines / Q000097:blood; D003071:Cognition; D001026:Coronary Artery Bypass; D017558:Elective Surgical Procedures; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D007442:Intubation, Intratracheal; D007530:Isoflurane / Q000008:administration & dosage; D007902:Length of Stay; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D017202:Myocardial Ischemia / Q000209:etiology; D010100:Oxygen / Q000097:blood; D011183:Postoperative Complications; D015742:Propofol / Q000008:administration & dosage; D011446:Prospective Studies; D016896:Treatment Outcome; D014692:Ventilation-Perfusion Ratio
D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D002395:Catecholamines; D007530:Isoflurane; D008874:Midazolam; D010100:Oxygen; D005283:Fentanyl; D015742:Propofol