Abstract
OBJECTIVES
The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery.
METHODS
A retrospective analysis was performed of prospectively collected data over a 4-year period (2011–14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score.
RESULTS
Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74–228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002).
CONCLUSIONS
OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.
Keywords: Cardiac surgery, Cardiac anaesthesia, Operation theatre, Early extubation, Elderly patients, Length of stay, EuroSCORE II, Age, Creatinine level, Left ventricular ejection fraction score
INTRODUCTION
Early extubation after cardiac surgery has been linked to safe improvements in postoperative length of stay (LOS), resource usage and mortality [1–4]. Primarily, early extubation seems to be cost-effective while attempting to preserve safety in selected groups of uncomplicated patients. Though there is no solid evidence, these protocols were also intended to decrease the risk of ventilator-associated nosocomial pneumonia, airway trauma and other pulmonary complications, enhance postoperative patient comfort by lowering stress due to intubation, reduce nurse dependency and facilitate earlier mobilization to decrease the risk of thromboembolic events [5–7]. Conversely, until now, experience with extubation in the operation theatre (OT) following on-pump cardiac surgery has remained rare and currently confined to highly selected patients and operation types [8–10]. Recently, new reports have provided more evidence for the safety and efficacy of OT extubation after off-pump and on-pump heart surgery in adult patients [11–13]. Based on propensity score-matched logistic regression analysis, other authors have encouraged programmatic transition from early postoperative extubation to immediate OT extubation in patients at low- and moderate-risk cardiac surgery to improve cost-effectiveness outcomes [14].
Although elderly patients could specially benefit from OT extubation programmes, no systematic study has been done to evaluate outcomes in this age group. In the past two decades, only a few studies have reported outcomes of early extubation after cardiac surgery in the elderly [15–17]. All these comparative works included patients over 65 or 70 years of age who exclusively underwent on-pump coronary bypass surgery. In these cases, 29–48% of patients were successfully extubated in the intensive care unit (ICU) within 6 h, and in some reports early extubation was associated with a significantly shorter postoperative LOS [15–16]. No attempt for OT extubation was done in those studies. In this work, we hypothesized that routine OT extubation may be a feasible and safe procedure even in elderly patients undergoing all types of cardiac surgery. The objective of this study was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate OT extubation after on-pump or off-pump cardiac surgery.
MATERIALS AND METHODS
A retrospective analysis was performed of prospectively collected data over a 4-year period (2011–14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years of age were preoperatively considered eligible for immediate OT extubation, after meeting specific postoperative criteria. All types of non-emergency on-pump and off-pump cardiac surgery were included, except acute aortic dissection, transcatheter aortic valve implantation (TAVI) and transplantation. TAVI was excluded from analysis because a learning curve for this procedure was being developed at our centre at the time of recruitment. Patients arriving at the OT with mechanical ventilation were also excluded. Cardiac surgical risk stratification was assessed with EuroSCORE II, and age, creatinine level and left ventricular ejection fraction (ACEF) score [18]. EuroSCORE values before 2012 were retrospectively calculated. Definition of chronic obstructive pulmonary disease (COPD) was adopted from the EuroSCORE II, considering only patients with long-term use of bronchodilators or steroids for lung disease. Baseline preoperative clinical variables and in-hospital outcome data were recorded and analysed with the approval of the local Institutional Review Board.
For analysis purposes, patients were divided into OT extubation and ICU extubation cohorts. Comparative clinical outcomes between groups were assessed with overall in-hospital mortality, complications, reintubation rate and hospital LOS according to extubation status. ICU LOS was not measured since it strongly depends on institutional issues such as step-down facilities and ward room availability, irrespective of the readiness for discharge.
Continuous variables were expressed as mean and standard deviation, or median and 25–75% percentiles (P25–75%). Kolmogorov–Smirnov goodness-of-fit test was used to analyse normal distributions. Continuous variables were compared using Student's t-test or the Mann–Whitney U-test. Univariate comparison of dichotomous variables was performed using the χ² test or Fisher's exact test when appropriate. Variables associated with OT extubation in the elderly (P ≤ 0.10) were entered in a multiple logistic regression analysis (conditional forward stepwise method) in an attempt to identify independent factors related to immediate OT extubation. The area under the receiver operating characteristics (ROC) curve was used to determine the best cut-off point of risk scores associated with successful OT extubation. The cut-off values were identified at the point where the ROC curve sum of sensitivity and specificity was highest according to the Yourden index. Sensitivity, specificity and positive (PPV) and negative predictive values (NPV) for each risk score cut-off point were calculated. Statistical analysis was done with SPSS Statistics for Windows, Version 17.0. Chicago, SPSS, Inc. A two-tailed P value ≤0.05 was considered statistically significant.
Anaesthesia and extubation protocol
Preoperative respiratory status was assessed with spirometry, chest radiograph and arterial blood gases. Depending on the time of hospitalization, between 1 day and 1 week before surgery, physiotherapists provided preoperative information to patients regarding early extubation, pain control and sternotomy restrictions, and trained them on assisted cough techniques and diaphragmatic breathing exercises [19].
All patients underwent similar protocolized anaesthesia induction, maintenance and awakening. A limited dose of a short-acting opioid (<100 mg fentanyl) premedication was administered on arrival to the OT. At the onset of anaesthesia, no benzodiazepine drugs were used. Patients were monitored by invasive radial arterial blood pressure, pulse oximetry, five-lead electrocardiogram with ST-segment analysis, end-tidal carbon dioxide, central venous pressure and nasopharyngeal temperature. Routine transoesophageal echocardiography was not performed, except to assess mitral or tricuspid valve repair, and a pulmonary artery catheter was placed if necessary. After induction of anaesthesia with propofol (1.5–2 mg/kg) and atracurium (0.6 mg/kg), a short-acting volatile agent (2–3% sevoflurane) was used to maintain anaesthesia before and during extracorporeal circulation. Anaesthesia was maintained only with inhalational agents, and additional doses of the opioid analgesic were used with discretion as needed. A supplementary dose of atracurium was used according to the length of surgery. All the patients underwent standard surgical procedures through median sternotomy, and when cardiopulmonary bypass was used, they were operated in normothermia with St Thomas antegrade cardioplegia. The authors did not routinely use bispectral monitoring to assess anaesthetic depth, and neuromuscular blockade was determined with signs of spontaneous ventilatory efforts, based on the capnographic curve. OT extubation was when the patient was extubated in the OT within 20 min after ending the cardiac surgery. The inhalational agent was stopped a few minutes before the end of surgery, usually during chest wiring and closure. Alveolar recruitment was achieved with a temporal 10 cmH2O positive end-expiratory pressure (PEEP), in the absence of unstable haemodynamics, bronchospasm or COPD. Following surgery completion, the neuromuscular blockade was reversed with atropine (15 mg/kg) and neostigmine (40 mg/kg), and patients were extubated once typical criteria were fulfilled. The extubation criteria included: (i) haemodynamic stability with no signs of low-cardiac-output syndrome or myocardial ischaemia, and without significant inotropic support; (ii) normothermia; (iii) absence of active mediastinal bleeding with normal activated coagulation time; (iv) adequate muscular strength assessed by limb movements and spontaneous ventilation sufficient to maintain arterial oxygen saturation over 95% with 50% FiO2 and end-tidal carbon dioxide under 50 mmHg and (v) a fully awake patient capable of following simple commands (opening eyes, sticking out the tongue and limb movements). The decision to extubate in the OT was taken in accordance with anaesthesiologist and surgeon opinion. Intravenous non-steroidal anti-inflammatory drugs (0.5–1 mg/kg diclofenac) were administered to further enhance analgesia following extubation. No patient received epidural anaesthesia for postoperative analgesia. Patients successfully extubated in the OT were directly transferred to the ICU with 50% FiO2 oxygen supplementation through a face mask. The patient was accompanied by the anaesthesiologist and an assistant surgeon, and surveillance during transportation was done with a multiparameter transport patient monitor. Postoperative analgesia after extubation was provided with ibuprofen/dextropropoxyphene, as appropriate to a pain scale score <10. Patients not fulfilling the extubation criteria were given temporary sedation and transported to the ICU.
Early postoperative ICU extubation was defined as that occurring within 6 h. Intubated patients admitted to the ICU were connected to mechanical ventilation in volume-controlled continuous mandatory ventilation mode (8 ml/kg body weight). During the postoperative period, patients received intravenous analgesic drugs, and non-steroidal anti-inflammatory drugs (ibuprofen/dextropropoxyphene 400 mg every 4–6 h, not >1.6 g/day). Invasive arterial blood pressure monitoring, pulse oximetry, five-lead ECG with ST-segment analysis, central venous pressure and echocardiography were assessed when needed. Weaning criteria were as follows: (i) haemodynamic stability without significant inotropic support (dopamine ≤5 μg/kg/min and noradrenaline ≤0.05 mg/kg/min); (ii) normothermia; (iii) mediastinal bleeding <100 ml within the first hour or <500 ml within 4 h; (iv) Richmond Agitation-Sedation Scale in the range −1/+1; (v) PaO2/ FiO2 ≥200 with PEEP <5–7 cmH2O and FiO2 ≤50%. Once weaning conditions were fulfilled, the formal assessment for mechanical ventilation discontinuation was performed by a spontaneous breathing test (SBT) using a T-piece with supplemental oxygen supply to ensure arterial oxygen saturation ≥94%. Weaning failure was considered when it was necessary to restore mechanical ventilation due to any of the following criteria: (i) increased respiratory rate >35 breaths/min; (ii) use of accessory muscles or paradoxical breathing; (iii) hypoxaemia (arterial oxygen saturation <90%); (iv) PaCO2 ≥50 mmHg; (v) heart rate >130 beats/min or more than 20% increase; (vi) change in systolic blood pressure <90 or >180 mmHg or more than 20% increase; (vii) sensory impairment; (viii) agitation, sweating and anxiety. After 30–120 min of successful SBT, extubation was performed based on the following criteria: (i) answer to four simple commands (open your eyes, turn your gaze, press my hand and stick out your tongue); (ii) airway protection; (iii) coughing force (maximal expiratory pressure ≥40 cm H2O); (iv) less than two nasopharyngeal aspirations required during SBT and (v) PaCO2 ≤50 mmHg.
RESULTS
Among the 415 patients operated during the period, 66.3% (n = 275) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The overall risk of reintubation within 24 h of surgery after OT extubation was 2.1% (n = 3), including 1 patient requiring reintubation because of surgical re-exploration for bleeding. Reintubation rate after 24 h was 3.6% (n = 5), and was related with late major complications or death between the fourth and ninth postoperative day. Non-invasive ventilation was used in patients with hypoxaemia after extubation. Seven patients (5.0%) extubated in the OT required bilevel positive airway pressure support, versus 11 patients (8.1%) extubated in the ICU (P = 0.291). The overall in-hospital mortality rate was 4.7% (n = 13), and the complication rate was 11.6% (n = 32), independently of the extubation timing.
In elderly patients, those extubated in the OT had a significantly lower average body mass index (BMI), lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time duration, less complications and shorter LOS than ICU-extubated patients (Table 1). Postoperative complications in patients undergoing immediate OT versus delayed ICU extubation are given in Table 2.
Table 1:
Comparison of baseline clinical characteristics and in-hospital outcomes of elderly patients undergoing immediate operation theatre or ICU extubation after cardiac surgery
| OT extubation (n = 140) | ICU extubation (n = 135) | P-value | |
|---|---|---|---|
| Age in years (mean, SD) | 75.2 (4.20) | 75.6 (4.59) | 0.599 |
| Male sex (n, %) | 79 (56.4) | 87 (64.4) | 0.174 |
| Body mass index (mean, SD) | 26.5 (3.75) | 27.6 (4.07) | 0.020 |
| COPD (n, %) | 18 (12.9) | 19 (14.1) | 0.767 |
| EuroSCORE II (median, P25–75%) | 1.8 (1.25–2.84) | 2.4 (1.70–3.74) | 0.012 |
| ACEF score (median, P25–75%) | 1.22 (1.12–1.33) | 1.36 (1.23–1.56) | <0.0001 |
| Off-pump CABG (n, %) | 19 (29.7) | 21 (30.4) | 0.925 |
| Type of surgery (n, %) | |||
| Coronary | 64 (45.7) | 69 (51.1) | – |
| Valve | 56 (40.0) | 30 (22.2) | – |
| Combined | 18 (12.9) | 23 (17.0) | – |
| Miscellaneous | 2 (1.4) | 13 (9.6) | – |
| Total | 140 (100) | 135 (100) | 0.001a |
| CPB time in min (mean, SD) | 61.1 (10.9) | 67.3 (14.7) | 0.011 |
| Cross-clamp time in min (mean, SD) | 39.1 (12.2) | 41.9 (11.7) | 0.220 |
| Mortality (n, %) | 4 (2.9) | 9 (6.7) | 0.162 |
| Complications (n, %) | 9 (6.4) | 23 (17.0) | 0.006 |
| Hospital LOS in days (median, P25–75%) | 5 (4–7.5) | 7 (5–10) | 0.038 |
OT: operation theatre; ICU: intensive care unit; COPD: chronic obstructive pulmonary disease; ACEF: age, creatinine and left ventricular ejection fraction; CABG: coronary artery bypass graft surgery; CPB: cardiopulmonary bypass; LOS: length-of-stay; SD: standard deviation.
aχ² test P-value for a 2 × 4 table.
Table 2:
Postoperative complications in elderly patients undergoing immediate operation theatre or ICU extubation after cardiac surgery
| Postoperative complications (n, %) | OT extubation (n = 140) | ICU extubation (n = 135) | Total (n = 275) |
|---|---|---|---|
| Pneumonia—distress | 3 (2.1) | 4 (3.0) | 7 (2.5) |
| Barotrauma from mechanical ventilation | 0 (0.0) | 2 (1.5) | 2 (0.7) |
| Pleural effusion | 2 (1.4) | 0 (0.0) | 2 (0.7) |
| Prolonged ventilation | 0 (0.0) | 1 (0.7) | 1 (0.4) |
| Renal failure—de novo dialysis | 1 (0.7) | 0 (1.5) | 3 (1.1) |
| Stroke | 0 (0.0) | 3 (2.2) | 3 (1.1) |
| Sudden death | 0 (0.0) | 3 (2.2) | 3 (1.1) |
| Reoperation for bleeding | 1 (0.7) | 1 (0.7) | 2 (0.7) |
| Sternal wound infection or dehiscence | 0 (0.0) | 2 (1.5) | 2 (0.7) |
| Infarction (Q type) | 0 (0.0) | 1 (0.7) | 1 (0.4) |
| Low-cardiac output | 0 (0.0) | 1 (0.7) | 1 (0.4) |
| Complete A-V block | 1 (0.7) | 1 (0.7) | 1 (0.4) |
| Others | 1 (0.7) | 2 (1.5) | 3 (1.1) |
OT: operation theatre; ICU: intensive care unit.
In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74–228.8, P = 0.004).The discriminatory power of the ACEF score to predict OT extubation (ROC area) was 0.713 (0.615–0.810), and the cut-off analysis showed that a value under 1.37 was associated with 58.3% OT extubation (PPV) versus 20.6% (100-NPV) when the value was over 1.37 (P = 0.0003). On the other hand, the EuroSCORE ROC area was 0.694 (0.597–0.791), and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation (PPV) versus 37.3% (100-NPV) when the risk value was over 2.11 (P = 0.0002). Relative sensitivity, specificity and positive and negative predictive values of the EuroSCORE II and ACEF score are presented in Table 3.
Table 3:
Cut-off values and relative sensitivity, specificity and positive and negative predictive values of the EuroSCORE II and ACEF score
| Risk score | Cut-off value | Sensitivity (%) | Specificity (%) | PPV (%) | NPV (%) |
|---|---|---|---|---|---|
| ACEF | 1.37 | 85.7 | 47.4 | 58.3 | 79.4 |
| EuroSCORE II | 2.11 | 69.8 | 65.3 | 72.1 | 62.7 |
PPV: positive predictive value; NPV: negative predictive value.
Upon arrival to the ICU, average laboratory values of elderly patients extubated in the OT were: pH 7.35 (95% CI 7.33–7.37), arterial O2 saturation 93.7% (95% CI 92.3–95.2) and arterial CO2 partial pressure 43.6 (95%CI 41.2–46.0).
DISCUSSION
Early extubation following adult cardiac surgery is an acknowledged international quality parameter, as prolonged mechanical ventilation has been linked to poorer outcomes [3, 14]. Consequently, application of standardized strategies is desirable to reduce postoperative extubation times. In this work, OT extubation was successfully performed in nearly 50% of elderly patients, without apparently worsening their outcomes. A key point of this success was the use of a volatile agent to maintain anaesthesia throughout the procedure. Furthermore, LOS was significantly shorter in the group with OT extubation. Similarly, more recent research performed in younger patients reported an ∼24-h shorter LOS with OT extubation [12–14].
In previous reports, OT extubation rates in patients between 59 and 69 years were in the range of 21–89% [10–11, 13–14, 20–21], with higher rates in off-pump surgeries [8–10, 12]. Though off-pump surgery was associated with higher rates of extubation in the OT in younger cohorts [8–10], we did not find differences in elderly patients when off-pump surgery was excluded from the analysis (50.9 vs 51.5%). This fact may be explained by assuming that elderly patients selected for off-pump surgery had higher risk scores, and in consequence, lower chance for OT extubation.
Furthermore, OT extubation in the elderly rarely resulted in tracheal reintubation. Previously published studies showed an estimated rate of reintubation of 0–3% after OT extubation in younger patients [6, 8, 11, 13, 22–23].
As stated in a previous publication [10], OT extubation should be avoided in obese patients with haemodynamic involvement. In the current work, average BMI was significantly lower in patients extubated in the OT.
A recent case series of 260 octogenarian patients undergoing cardiac surgery was reported by Scandroglio et al. [24]. Average duration of mechanical ventilation was 15 h, 2.3% of patients required reintubation and the in-hospital mortality rate was 3.9%. In contrast, we achieved nearly 50% OT extubations with a 2.1% reintubation rate and a 4.7% in-hospital mortality rate in a population 7 years younger.
Elderly patients were more probably extubated in the OT if they had lower BMI, lower EuroSCORE risk level or ACEF score, shorter cardiopulmonary bypass time duration or underwent isolated valve surgery. In this work, patients to be extubated in the OT were intraoperatively identified; however, the preoperative ACEF score and the EuroSCORE II were useful predictors for OT extubation in the elderly. Though only the ACEF score remained as independent predictor of OT extubation after multivariate analysis, both the ACEF score and the EuroSCORE seem to be accurate predictors of extubation when their values are under 1.37 and 2.11, respectively. Based on ROC analysis cut-off values, the EuroSCORE showed a better positive predictive value (72.1%), and the ACEF score a better negative predictive value (79.4%). Since the ACEF score and the EuroSCORE II include several preoperative variables, these single values could be used to select candidates for attempting OT extubation. In a previous work, we found that some preoperative variables such as heart failure, pulmonary disease, left ventricular dysfunction and urgent status were related to failed tracheal extubation [10]; all these preoperative factors were included in the EuroSCORE II used in the current series. Operative variables such as cross-clamping time, pacemaker requirement and difficult cardiopulmonary bypass weaning were also related to failed OT extubation [10], but not considered in the current work. Independently of perioperative factors, successful OT extubation definitively depends on fulfilling the traditional extubation criteria after the implementation of a low-dose bendodiazepine/opioid anaesthetic protocol, and in absence of intraoperative events.
A catecholamine stress response or hypoxia-related injury associated with premature extubation that could result in myocardial ischaemia generate controversy with OT extubation [25]. Other arguments include the high incidence of bleeding and airway complications in the immediate postoperative period, where delaying extubation would help to stabilize those issues before weaning the patient [14]. In our work, immediate extubation before leaving the OT seemed not to increase the risk for cardiac arrhythmias secondary to ischaemia, or Q-type infarction. It is probable that elderly patients have a reduced adrenergic and inflammatory response that avoids these complications. Moreover, the need of reoperation for bleeding was <1%, and airway complications were 3.6% in those extubated in the OT, only including pulmonary distress, pneumonia and pleural effusion.
Improvement in both patient comfort and resource usage seems to be achieved by OT extubation in the elderly, since it may be performed safely without an increase in morbidity, mortality or reintubation, and with a significant reduction of LOS across all types of cardiac operations. However, some limitations must be considered. The present study from a single institution was observational and retrospective in design, and other variables not included in the analysis could have affected the results. Furthermore, the study was not adequately powered to detect the difference in isolated complications, considering the low event rates for outcomes. The present analysis did not determine whether the better outcomes observed in patients extubated in the OT depended on healthier patients or because there existed a real benefit with OT extubation. Anaesthesiologists and surgeons may be reluctant to extubate a patient in the OT if they believe that a particular case is at risk for postoperative complications. This position has led to a possible selection bias, since patients deemed at risk will not be considered suitable candidates for extubation. In spite of some ethical restrictions, ideally, a future prospective, randomized, controlled clinical trial will overcome these limitations, and demonstrate a causal relationship between extubation timing and outcomes.
In conclusion, OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. Though a possible selection bias must be considered, a low reintubation risk and significant reduction in hospital LOS were also observed when comparing with ICU-extubated patients. Finally, we found that low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly. Moreover, the ACEF score remained as an independent predictor of OT extubation after multivariate analysis, with good discriminating power and an adequate negative predictive value.
Conflict of interest: none declared.
REFERENCES
- 1.Hillis DL, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation 2011;124:e652–735. [DOI] [PubMed] [Google Scholar]
- 2.Zhu F, Lee A, Chee YE. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 2012;10:CD003587. [DOI] [PubMed] [Google Scholar]
- 3.Reis J, Mota JC, Ponce P, Costa-Pereira A, Guerreiro M. Early extubation does not increase complication rates after coronary artery bypass graft surgery with cardiopulmonary bypass. Eur J Cardiothorac Surg 2002;21:1026–30. [DOI] [PubMed] [Google Scholar]
- 4.Silbert BS, Santamaria JD, O'Brien JL, Blyth CM, Kelly WJ, Molnar RR. Early extubation following coronary artery bypass surgery: a prospective randomized controlled trial. The Fast Track Cardiac Care Team. Chest 1998;113:1481–8. [DOI] [PubMed] [Google Scholar]
- 5.Reddy SLC, Grayson AD, Griffiths EM, Pullan DM, Rashid A. Logistic risk model for prolonged ventilation after adult cardiac surgery. Ann Thorac Surg 2007;84:528–36. [DOI] [PubMed] [Google Scholar]
- 6.Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients. Cochrane Database Systematic Rev 2003;4:CD003587. [DOI] [PubMed] [Google Scholar]
- 7.Meade MO, Guyatt G, Butler R, Elms B, Hand L, Ingram A et al. Trials comparing early vs. late extubation following cardiovascular surgery. Chest 2001;120:445S–53S. [DOI] [PubMed] [Google Scholar]
- 8.Royse CF, Royse AG, Soeding PF. Routine immediate extubation after cardiac operation: a review of our first 100 patients. Ann Thorac Surg 1999;68:1326–9. [DOI] [PubMed] [Google Scholar]
- 9.Straka Z, Brucek P, Vanek T, Votava J, Widimsky P. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 2002;74:1544–7. [DOI] [PubMed] [Google Scholar]
- 10.Borracci RA, Dayán R, Rubio M, Axelrud G, Ochoa G, Rodríguez LD. Operation theatre extubation (ultra fast-track anesthesia) in patients undergoing on-pump and off-pump cardiac surgery. Arch Cardiol Mex 2006;76:383–9. [PubMed] [Google Scholar]
- 11.Rodriguez Blanco YF, Candiotti K, Gologorsky A, Tang F, Giquel J, Barron ME et al. Factors which predict safe extubation in the operation theatre following cardiac surgery. J Card Surg 2012;27:275–80. [DOI] [PubMed] [Google Scholar]
- 12.Dorsa AG, Rossi AI, Thierer J, Lupiañez B, Vrancic JM, Vaccarino GN et al. Immediate extubation after off-pump coronary artery bypass graft surgery in 1,196 consecutive patients: feasibility, safety and predictors of when not to attempt it. J Cardiothorac Vasc Anesth 2011;25:431–6. [DOI] [PubMed] [Google Scholar]
- 13.Chamchad D, Horrow JC, Nachamchik L, Sutter FP, Samuels LE, Trace CL et al. The impact of immediate extubation in the operation theatre after cardiac surgery on intensive care and hospital lengths of stay. J Cardiothorac Vasc Anesth 2010;24:780–4. [DOI] [PubMed] [Google Scholar]
- 14.Badhwar V, Esper S, Brooks M, Mulukutla S, Hardison R, Mallios D et al. Extubating in the operation theatre after adult cardiac surgery safely improves outcomes and lowers costs. J Thorac Cardiovasc Surg 2014;148:3101–9. [DOI] [PubMed] [Google Scholar]
- 15.Guller U, Anstrom KJ, Holman WL, Allman RM, Sansom M, Peterson ED. Outcomes of early extubation after bypass surgery in the elderly. Ann Thorac Surg 2004;77:781–8. [DOI] [PubMed] [Google Scholar]
- 16.Lee JH, Graber R, Popple CG, Furey E, Lyons T, Murrell HK et al. Safety and efficacy of early extubation of elderly coronary artery bypass surgery patients. J Cardiothorac Vasc Anesth 1998;12:381–4. [DOI] [PubMed] [Google Scholar]
- 17.Ott RA, Gutfinger DE, Miller MP, Alimadadian H, Tanner TM. Rapid recovery after coronary artery bypass grafting: is the elderly patient eligible? Ann Thorac Surg 1997;63:634–9. [DOI] [PubMed] [Google Scholar]
- 18.Ranucci M, Castelvecchio S, Menicanti L, Frigiola A, Pelissero G. Risk of assessing mortality risk in elective cardiac operations: age, creatinine, ejection fraction, and the law of parsimony. Circulation 2009;119:3053–61. [DOI] [PubMed] [Google Scholar]
- 19.Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev 2012;11:CD010118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Oxelbark S, Bengtsson L, Eggersen M, Kopp J, Pedersen J, Sanchez R. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 2001;19:460–3. [DOI] [PubMed] [Google Scholar]
- 21.Hemmerling TM, Le N, Olivier JF, Choiniere J, Basile F, Prieto F. Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia. J Cardiothorac Vasc Anesth 2005;19:178–81. [DOI] [PubMed] [Google Scholar]
- 22.Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? JAMA 1983;249:1743–5. [PubMed] [Google Scholar]
- 23.Montes FR, Sanchez SI, Giraldo JC, Rincón JD, Rincón IE, Vanegas MV et al. The lack of benefit of tracheal extubation in the operation theatre after coronary artery bypass surgery. Anesth Analg 2000;91:776–80. [DOI] [PubMed] [Google Scholar]
- 24.Scandroglio AM, Finco G, Pieri M, Ascari R, Calabró MG, Taddeo D et al. Cardiac surgery in 260 octogenarians: a case series. BMC Anesthesiol 2015;15:15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Sullivan BL. Con: early extubation in the operation theatre following cardiac surgery. Semin Cardiothorac Vasc Anesth 2012;16:187–9. [DOI] [PubMed] [Google Scholar]