title: Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.
abstract: OBJECTIVE
  Prolonged intubation has been implicated in the poor outcomes after adult cardiac surgery. Accelerated postoperative extubation has been a quality focus, but operating room (OR) extubation after cardiopulmonary bypass is rare. We examined the outcomes and direct costs of protocolized OR extubation versus early postoperative intensive care unit (ICU) extubation after nonemergency open cardiac surgery.
  
  
  METHODS
  From January 2012 to June 2013, 652 consecutive patients who had undergone various cardiac operations, including redo and multivalve operations, were extubated within 12 hours, 165 in the OR. The OR extubation patients were propensity matched from multivariable logistic regression to derive 106 matched pairs for OR extubation versus extubation < 12 hours (group 1) and 98 independently matched pairs for OR extubation versus extubation < 6 hours (group 2).
  
  
  RESULTS
  OR versus ICU extubation conveyed significant reductions in ICU hours (26.3, interquartile range [IQR], 22.0-31.0; vs 29.0, IQR, 25.0-51.0; P = .001, for group 1; 27.0, IQR, 22.0-32.0; vs 29.0, IQR, 25.0-54.0; P = .0002, for group 2) and postoperative length of stay (5 days, IQR, 4-6; vs 6 days, IQR, 5-7; P = .0008, for group 1; 5 days, IQR, 4-6; vs 6 days, IQR, 4-7; P = .0002, for group 2) but did not affect the reintubation rate (1.9% [2 of 106] vs 0.0% [0 of 106], P = .5, group 1; 3.1% [3 of 98] vs 2.0% [2 of 98], P = 1.0, group 2). OR versus ICU extubation conferred a >20% cost reduction from surgery completion to discharge ($3055, IQR, $2576-$3964; vs $3977, IQR, $3028-$4947; P = .0007, group 1; $3025, IQR, $2598-$3965, vs $3877, IQR, $2998-$5458; P = .007, group 2).
  
  
  CONCLUSIONS
  After cardiac surgery, OR extubation is safe and might provide improvement in length of stay and cost compared with early postoperative ICU extubation.
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: badhwarv@upmc.edu.
authors.forename: Vinay
authors.initials: V
authors.lastname: Badhwar
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Stephen
authors.initials: S
authors.lastname: Esper
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Maria
authors.initials: M
authors.lastname: Brooks
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Suresh
authors.initials: S
authors.lastname: Mulukutla
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Regina
authors.initials: R
authors.lastname: Hardison
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Demetri
authors.initials: D
authors.lastname: Mallios
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Danny
authors.initials: D
authors.lastname: Chu
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Wei
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Kathirvel
authors.initials: K
authors.lastname: Subramaniam
mesh_terms: D000368:Aged; D060666:Airway Extubation / Q000009:adverse effects / Q000191:economics*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000191:economics*; D016009:Chi-Square Distribution; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007362:Intensive Care Units / Q000191:economics; D007902:Length of Stay / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D009873:Operating Rooms / Q000191:economics*; D061214:Patient Safety / Q000191:economics*; D057216:Propensity Score; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome