title: Early Extubation: A Proposed New Metric.
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.
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Crawford
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jonathan Trent
authors.initials: JT
authors.lastname: Magruder
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Grimm
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Christopher
authors.initials: C
authors.lastname: Sciortino
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
authors.affiliation: Divison of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Bo S
authors.initials: BS
authors.lastname: Kim
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Higgins
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Duke E
authors.initials: DE
authors.lastname: Cameron
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Marc
authors.initials: M
authors.lastname: Sussman
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: gwhitman@jhmi.edu.
authors.forename: Glenn J
authors.initials: GJ
authors.lastname: Whitman
mesh_terms: D000368:Aged; D060666:Airway Extubation / Q000009:adverse effects / Q000401:mortality; D015142:Baltimore; D019985:Benchmarking; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000401:mortality; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D019984:Quality Indicators, Health Care; D012121:Respiration, Artificial / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Mechanical ventilation; Operative mortality; Society of Thoracic Surgeons; Ventilation time; multivariable logistic regression