title: Early extubation reduces respiratory complications and hospital length of stay following repair of abdominal aortic aneurysms.
abstract: BACKGROUND
  Early extubation after cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (endovascular aneurysm repair [EVAR], 77%-97%; open repair, 30%-70%) after repair of intact abdominal aortic aneurysms (AAAs). However, the effects of extubation practices on patient outcomes after repair of AAAs are unclear.
  
  
  METHODS
  All patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003 to 2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (operating room, <12 hours, >12 hours) and open repair (operating room, <12 hours, 12-24 hours, >24 hours). Prolonged hospital stay was defined as >2 days after EVAR and >7 days after open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified.
  
  
  RESULTS
  There were 5774 patients evaluated (EVAR, 4453; open repair, 1321). After both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12-hour delay in extubation: respiratory (EVAR: odds ratio [OR], 4.3 [95% confidence interval (CI), 3.0-6.1]; open repair: OR, 1.8 [95% CI, 1.5-2.2]), prolonged hospital stay (EVAR: OR, 2.7 [95% CI, 2.0-3.8]; open repair: OR, 1.3 [95% CI, 1.1-1.4]), and discharge to SNF (EVAR: OR, 2.0 [95% CI, 1.5-2.8]; open repair: OR, 1.4 [95% CI, 1.1-1.6]). Predictors of extubation outside of the operating room after EVAR included increasing age (OR, 1.5; 95% CI, 1.2-1.8), congestive heart failure (OR, 1.9; 95% CI, 1.2-3.0), chronic obstructive pulmonary disease (OR, 2.0; 95% CI, 1.4-2.9), symptomatic aneurysm (OR, 3.8; 95% CI, 2.3-5.7), and increasing diameter (OR, 1.01; 95% CI, 1.01-1.01). After open repair, increasing age (OR, 1.4; 95% CI, 1.1-1.6), congestive heart failure (OR, 1.8; 95% CI, 1.01-3.3), dialysis (OR, 2.8; 95% CI, 1.7-70), symptomatic aneurysm (OR, 2.8; 95% CI, 1.9-4.3), and hospital practice patterns (OR, 1.01; 95% CI, 1.01-1.01) were predictive of extubation outside of the operating room.
  
  
  CONCLUSIONS
  The benefits of early extubation in cardiac patients are also seen after AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to an SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and to improve patient outcomes.
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, George Washington University, Washington, D.C.
authors: Sara L
authors: SL
authors: Zettervall
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Peter A
authors: PA
authors: Soden
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Katie E
authors: KE
authors: Shean
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Sarah E
authors: SE
authors: Deery
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors: Klaas H J
authors: KH
authors: Ultee
authors: Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt.
authors: Matthew
authors: M
authors: Alef
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass.
authors: Jeffrey J
authors: JJ
authors: Siracuse
authors: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors: Marc L
authors: ML
authors: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D060666:Airway Extubation; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D007902:Length of Stay; D016015:Logistic Models; D008168:Lung / Q000503:physiopathology*; D008171:Lung Diseases / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D008297:Male; D015999:Multivariate Analysis; D009511:New England; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D016016:Proportional Hazards Models; D012119:Respiration; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome