title: Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative.
abstract: Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery.
  
  
  
  We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 in hospitals participating in the Vascular Quality Initiative (VQI). Our primary outcome was prolonged LOS (>7 days), and the secondary outcome was respiratory complications (pneumonia or reintubation). The association between extubation timing and outcomes was assessed using multivariable logistic regression mixed-effects models that adjusted for confounding factors at the patient and procedure level. A variable importance analysis was conducted using a chi-pie framework to identify factors contributing to the variability of extubation timing.
  
  
  
  The 7171 patients undergoing abdominal aortic surgery were a mean age of 65.4 (standard deviation, 10.2) years, and 63% were male. Extubation occurred (1) in the operating room (76.3%), (2) <12 hours (10.9%), (3) 12 to 24 hours (7.2%), or (4) >24 hours (5.6%) after surgery. Hospitals in the top quartile for case volume had the highest percentage of patients extubated in the operating room (82.8%). Patients least likely to be extubated in the operating room were older, more likely to have chronic obstructive pulmonary disease, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS (<12 hours: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; 12-24 hours: OR, 2.1; 95% CI, 1.7-2.7; >24 hours: OR, 5.3; 95% CI, 4.0-6.9), and pulmonary complications (<12 hours: OR, 1.9; 95% CI, 1.4-2.6; 12-24 hours: OR, 2.6; 95% CI, 1.8-3.6; >24 hours: OR, 9.6; 95% CI, 7.1-13.0) compared with those extubated in the operating room. Subset analysis of patients extubated in the operating room or <12 hours showed that extubation out of the operating room was associated with prolonged LOS (OR, 1.4; 95% CI, 1.2-1.7) and pulmonary complications (OR, 1.8; 95% CI, 1.3-2.5). The variable importance analysis demonstrated that EBL (26%) and procedure time (24%) accounted for half of the variation in extubation timing.
  
  
  
  Extubation in the operating room is associated with shorter LOS and morbidity after open aortic surgery. EBL, procedure time, and center variation account for variability in extubation timing. These data advocate for standardized perioperative respiratory care to reduce variation, improve outcomes, and reduce LOS.
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Ramoncito A
authors.initials: RA
authors.lastname: David
authors.affiliation: Division of Vascular Surgery, University of Utah, Salt Lake City, Utah.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.affiliation: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Kristine T
authors.initials: KT
authors.lastname: Hanson
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Genovese
authors.affiliation: Division of Vascular Surgery, University of California, Los Angeles, Los Angeles, Calif.
authors.forename: Donald T
authors.initials: DT
authors.lastname: Baril
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Peter
authors.initials: P
authors.lastname: Gloviczki
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address: demartino.randall@mayo.edu.
authors.forename: Randall R
authors.initials: RR
authors.lastname: DeMartino
mesh_terms: D000368:Aged; D060666:Airway Extubation / Q000009:adverse effects; D001011:Aorta / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007442:Intubation, Intratracheal; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge; D011014:Pneumonia / Q000209:etiology / Q000628:therapy; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects