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Multicenter Study
. 2019 Aug;108(2):432-442.
doi: 10.1016/j.athoracsur.2019.04.013. Epub 2019 May 10.

Association of Overnight Extubation With Outcomes After Cardiac Surgery in the Intensive Care Unit

Hayley B Gershengorn  1 , Hannah Wunsch  2 , May Hua  3 , Joseph E Bavaria  4 , Jacob Gutsche  5
Affiliations
Multicenter Study

Association of Overnight Extubation With Outcomes After Cardiac Surgery in the Intensive Care Unit

Hayley B Gershengorn et al. Ann Thorac Surg. 2019 Aug.

Abstract

Background: The frequency and safety of overnight extubation (OE) after cardiac surgery across intensive care units (ICUs) is unknown.

Methods: We performed a retrospective study of adults (≥ 18 years) in US ICUs after coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both, using The Society of Thoracic Surgery Adult Cardiac Surgery Database (July 2014 to June 2017); our primary cohort was elective CABGs. We assessed OE (7:00 pm to 6:59 am) frequency and used multilevel regression modelling to identify factors associated with OE. Within mechanical ventilation (MV) duration strata, we used propensity score matching to evaluate associations of OE with reintubations (primary outcome), mortality, and complications.

Results: Among 142,225 patients with elective CABG, 42.2% had OEs. MV duration, cardiopulmonary bypass time, distal anastomosis number, and hospital of admission (median odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.76 to 1.89) were independently associated with OE. After propensity matching, OE was associated with increased reintubation for patients with MV duration of 6 to 8 hours (2.2% vs 1.7%, OR 1.27, 95% CI: 1.04 to 1.56) and decreased reintubation for patients with MV duration of 15 to 17 hours (3.0% vs 4.2%, OR 0.70, 95% CI: 0.50 to 0.97) and 18 to 20 hours (2.3% vs 5.7%, OR 0.39, 95% CI: 0.21 to 0.72); OE was associated with increased ICU length of stay for patients with MV duration of 6 to 8 hours, but reduced length of stay for patients with MV duration of 9 to 20 hours. OE was not associated with increased mortality (hospital, 30-day). Other groups had similar OE rates (nonelective CABGs, 47.6%; elective AVR, 36.0%; elective CABG + AVRs, 51.0%) and outcomes.

Conclusions: OE is prevalent after cardiac surgery. OE is associated with little risk and reduces ICU length of stay for patients who require MV for more than 8 hours.

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Figures

Figure 1.
Figure 1.
Timing of Extubation in the Intensive Care Unit for Elective Coronary Artery Bypass Graft Patients.a a 42.2% extubated overnight (7pm-6:59am)
Figure 2.
Figure 2.
Adjusted Association of Overnight Extubation with Reintubation for Elective Coronary Artery Bypass Graft Patients. A Primary Analysis—Propensity-Matched Pairs B. Sensitivity Analysis 1—Multilevel Multivariable Regression C. Sensitivity Analysis 2—Propensity-Matched Pairs, Overnight Defined as Midnight-4:59am CI: confidence interval; MV: mechanical ventilation
Figure 2.
Figure 2.
Adjusted Association of Overnight Extubation with Reintubation for Elective Coronary Artery Bypass Graft Patients. A Primary Analysis—Propensity-Matched Pairs B. Sensitivity Analysis 1—Multilevel Multivariable Regression C. Sensitivity Analysis 2—Propensity-Matched Pairs, Overnight Defined as Midnight-4:59am CI: confidence interval; MV: mechanical ventilation
Figure 2.
Figure 2.
Adjusted Association of Overnight Extubation with Reintubation for Elective Coronary Artery Bypass Graft Patients. A Primary Analysis—Propensity-Matched Pairs B. Sensitivity Analysis 1—Multilevel Multivariable Regression C. Sensitivity Analysis 2—Propensity-Matched Pairs, Overnight Defined as Midnight-4:59am CI: confidence interval; MV: mechanical ventilation
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 3.
Figure 3.
Adjusted Association of Overnight Extubation with Secondary Outcomes for Elective Coronary Artery Bypass Graft Patients. A. ICU Length of Stay B. ICU Readmission C. Any Complication D. Skin/Soft Tissue Infection E. Hospital Mortality F. 30-Day Mortality G. Discharge Home H. 30-Day Hospital Readmission CI: confidence interval; MV: mechanical ventilation a displayed as odds of “not going home” to allow for consistency in x-axis with other panels
Figure 4.
Figure 4.
Adjusted Association of Overnight Extubation with Reintubation for Additional Cohorts. A. Non-Elective Coronary Artery Bypass Graft B. Elective Aortic Valve Replacement C. Elective Coronary Artery Bypass Graft plus Aortic Valve Replacement CI: confidence interval; MV: mechanical ventilation
Figure 4.
Figure 4.
Adjusted Association of Overnight Extubation with Reintubation for Additional Cohorts. A. Non-Elective Coronary Artery Bypass Graft B. Elective Aortic Valve Replacement C. Elective Coronary Artery Bypass Graft plus Aortic Valve Replacement CI: confidence interval; MV: mechanical ventilation
Figure 4.
Figure 4.
Adjusted Association of Overnight Extubation with Reintubation for Additional Cohorts. A. Non-Elective Coronary Artery Bypass Graft B. Elective Aortic Valve Replacement C. Elective Coronary Artery Bypass Graft plus Aortic Valve Replacement CI: confidence interval; MV: mechanical ventilation
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