[Operating room extubation (ultra fast-track anesthesia) in patients undergoing on-pump and off-pump cardiac surgery].
OBJECTIVE
The potential benefit of immediate operating room extubation after cardiac surgery remains controversial. Since safety and effectiveness of ultra fast-track anesthesia is mandatory, we developed this work to identify preoperative and operative variables associated to failed extubation after on-pump and off-pump cardiac surgery.


METHODS
Three hundred ninety eight consecutive patients undergoing coronary, valve or combined surgery were included in a prospective observational study of ultra fast-track anesthesia. Primary outcome was failed tracheal extubation, defined as the impossibility to extubate in the operating room immediately after surgery. Secondary outcomes evaluated need for postoperative tracheal reintubation, morbidity and mortality. Univariate analysis and multivariate logistic regression were done over 24 preoperative and operative variables to determine factors associated with failed tracheal extubation after on-pump and off-pump surgery.


RESULTS
Sixty eight per cent of patients undergoing on-pump surgery, and 87.1% of those undergoing off-pump coronary revascularization were successfully extubated in the operating room. Univariate analysis in the on-pump group found that heart failure, left ventricular dysfunction, urgency, cross-clamping time, pacemaker requirement and difficult cardiopulmonary by-pass weaning were related to failed tracheal extubation; while heart failure and difficult cardiopulmonary bypass weaning were variables associated in the multivariate analysis. In the off-pump coronary surgery group, univariate analysis showed that pulmonary disease, urgency, pacemaker requirement and hemodynamic compromise during 'heart dislocation' were associated to failed extubation in the operating room. In this case, logistic analysis found obesity, pacemaker usage and hemodynamic compromise as factors related to failed extubation.


CONCLUSIONS
Preoperative and operative factors associated to failed extubation could be used as guidelines to improve safety in ultra fast-track cardiac anesthesia. Especially, patients undergoing on-pump surgery with antecedents of heart failure or difficult cardiopulmonary by-pass weaning should not be extubated in the operating room. In the same way, immediate extubation should be avoided in obese patients with hemodynamic compromise during off-pump coronary surgery.
Borracci
Raúl A
RA
Servicios de Cirugía Cardíaca, Anestesiologia y Cardiologia de la Clínica Bazterrica, Buenos Aires, Corporación Médica de Gral. San Martín, San Martín y Sanatorio Prof. Itoiz, Avellaneda, Buenos Aires, Argentina. borracci@universia.com.ar
Dayán
Rubén
R
Rubio
Miguel
M
Axelrud
Gerardo
G
Ochoa
Gustavo
G
Rodríguez
Leandro D
LD
D000368:Aged; D000758:Anesthesia / Q000379:methods*; D000762:Anesthesia Recovery Period; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D047549:Coronary Artery Bypass, Off-Pump; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D009873:Operating Rooms; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors