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. 2022 Jul 21:12:299-305.
doi: 10.1016/j.xjon.2022.07.006. eCollection 2022 Dec.

A 3-hour fast-track extubation protocol for early extubation after cardiac surgery

Mohammad A Helwani  1 , Cynthia Copeland  2 , Clare H Ridley  1 , Heiko A Kaiser  3 , Charl J De Wet  1
Affiliations

A 3-hour fast-track extubation protocol for early extubation after cardiac surgery

Mohammad A Helwani et al. JTCVS Open. .

Abstract

Objectives: Early extubation after cardiac surgery improves outcomes and reduces cost. We investigated the effect of a multidisciplinary 3-hour fast-track protocol on extubation, intensive care unit length of stay time, and reintubation rate after a wide range of cardiac surgical procedures.

Methods: We performed an observational study of 472 adult patients undergoing cardiac surgery at a large academic institution. A multidisciplinary 3-hour fast-track protocol was applied to a wide range of cardiac procedures. Data were collected 4 months before and 6 months after protocol implementation. Cox regression model assessed factors associated with extubation time and intensive care unit length of stay.

Results: A total of 217 patients preprotocol implementation and 255 patients postprotocol implementation were included. Baseline characteristics were similar except for the median procedure time and dexmedetomidine use. The median extubation time was reduced by 44% (4:43 hours vs 3:08 hours; P < .001) in the postprotocol group. Extubation within 3 hours was achieved in 49.4% of patients in the postprotocol group compared with 25.8% patients in the preprotocol group; P < .001. There was no statistically significant difference in the intensive care unit length of stay after controlling for other factors. Early extubation was associated with only 1 patient requiring reintubation in the postprotocol group.

Conclusions: The multidisciplinary 3-hour fast-track extubation protocol is a safe and effective tool to further reduce the duration of mechanical ventilation after a wide range of cardiac surgical procedures. The protocol implementation did not decrease the intensive care unit length of stay.

Keywords: 3-FTE, 3-hour fast-track extubation; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; IABP, intra-aortic balloon pump; ICU, intensive care unit; LOS, length of stay; cardiac surgery; early extubation; multidisciplinary protocol.

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Figures

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Graphical abstract
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Extubation time was decreased with the application of the 3-FTE protocol.
Figure 1
Figure 1
3-FTE protocol. PRVC, Pressure regulated volume control; SIMV, synchronized intermittent mandatory ventilation; TV, tidal volume; IBW, ideal body weight; PEEP, positive end-expiratory pressure; RR, respiratory rate; EtCO2, end tidal carbon dioxide; FiO2, fraction of inspired O2; OR, operating room; COPD, chronic obstructive pulmonary disease; ABG, arterial blood gas; RASS, Richmond Agitation Sedation Scale; PRN, as needed; MD, medical doctor; APP, advance practice provider; CI, cardiac index; HCO3, bicarbonate; PSV, pressure support ventilation; RSBI, rapid shallow breathing index; MV, minute ventilation; PO2, partial pressure of oxygen.
Figure 2
Figure 2
Extubation time before and during the 3-FTE protocol implementation: extubation time shortened after protocol implementation. The number of subjects at risk or evaluated for extubation are shown periodically along and below the X axis and as percentage of patients extubated on the Y axis. The 95% confidence limits are shown as shading along the lines. The individual graph lines are truncated before the number of subjects at risk decreases to less than 10. 3-FTE, 3-hour fast-track extubation protocol.
Figure 3
Figure 3
Factors impacting extubation time after cardiac surgery after controlling for other variables. HR, Hazard ratio; CI, confidence interval; CABG, coronary artery bypass grafting; AVR, aortic valve replacement; FTE, fast-track extubation protocol; BMI, body mass index; COPD, chronic obstructive pulmonary disease.
Figure 4
Figure 4
Summary of the main findings before and after 3-FTE protocol and factors affecting time to extubation after a wide range of cardiac surgical procedures.
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