Operating Room Extubation may not Increase Postoperative Delirium or Reintubation Rates, but Reduces Intubation Duration: Study

Comparison of Outcomes and Factors Analysed

The study compared outcomes before and after implementation of the OR extubation protocol, which was initiated on August 20, 2020. Delirium rates, reintubation rates, and intubation duration were assessed. Logistic regression was used to identify patient perioperative characteristics associated with unsuccessful OR extubation.

Patient Distribution and Characteristics

Of the 312 patients, 254 were extubated in the intensive care unit (ICU) and 58 in the OR. Preoperative demographics were generally similar between the two groups, except the OR extubation group had a lower median Charlson Comorbidity Index (1.5 vs 2.0).

Analysis and Post-implementation Findings

Interrupted time series analysis showed no significant change in postoperative delirium rates after implementation of the OR extubation protocol, with a trend towards decreasing delirium (risk ratio = 0.37, 95% CI: 0.13-1.10, p=0.07). The post-implementation era also had a lower median intubation duration (8 hours vs 13 hours, p<0.001) without increasing reintubation rates (1.7% vs 7.9%, p=0.159). Factors associated with decreased odds of successful OR extubation included increased bypass length (OR=0.99, 95% CI: 0.98-0.99, p<0.001), higher intraoperative morphine milligram equivalents (OR=0.99, 95% CI: 0.99-1.0, p=0.009), and a preoperative Charlson Comorbidity Index above 3 (OR=0.42, 95% CI: 0.19-0.95, p=0.037). In conclusion, implementation of an OR extubation protocol for minimally invasive cardiac valve surgery was not associated with increased postoperative delirium or reintubation rates, but did decrease intubation duration. Successful OR extubation appears to depend on consideration of various patient perioperative characteristics.

Key Points

1. The study examined the safety and feasibility of implementing an operating room (OR) extubation protocol for patients undergoing minimally invasive cardiac valve surgery.

2. The study compared outcomes before and after implementation of the OR extubation protocol, including delirium rates, reintubation rates, and intubation duration.

3. Of the 312 patients, 254 were extubated in the intensive care unit (ICU) and 58 in the OR. The OR extubation group had a lower median Charlson Comorbidity Index.

4. Interrupted time series analysis showed no significant change in postoperative delirium rates after implementation of the OR extubation protocol, with a trend towards decreasing delirium. The post-implementation era also had a lower median intubation duration without increasing reintubation rates.

5. Factors associated with decreased odds of successful OR extubation included increased bypass length, higher intraoperative morphine milligram equivalents, and a preoperative Charlson Comorbidity Index above 3.

6. Implementation of an OR extubation protocol for minimally invasive cardiac valve surgery was not associated with increased postoperative delirium or reintubation rates, but did decrease intubation duration. Successful OR extubation appears to depend on consideration of various patient perioperative characteristics.

Reference –

Chen Chia Wang et al. (2024). Safe Landing: Feasibility And Safety Of Operating Room Extubation In Minimally Invasive Cardiac Valve Surgery.. *Journal Of Cardiothoracic And Vascular Anesthesia*.https://doi.org/10.1053/j.jvca.2024.09.014