TIMING OF TRACHEAL EXTUBATION IN ADULT CARDIAC-SURGERY PATIENTS

In this article, we examine 14 studies conducted from 1974 to 1994 on ''early'' endotracheal extubation (0 to 12 hours postoperatively) in a dult cardiac surgery patients. Aspects reviewed include: criteria for patient selection; criteria for extubation; analyses of feasibility an d safety; effects of anesthetic technique; and patient morbidity. Adva ntages and disadvantages of early or ''fast-track'' extubation are dis cussed as are directions for future research. Selection criteria varie d among studies; patients were most commonly excluded because of sever e, preexisting pulmonary disease or ventricular dysfunction. Based on the studies examined, however, at least 70% to 80% of adult patients w ould meet selection criteria. Three universal criteria were applied in all studies: (1) patient is awake and responsive; (2) adequate gas ex change while breathing spontaneously; and (3) cardiovascular stability . To facilitate early extubation in appropriately selected patients, t he choice of anesthetic technique and postoperative sedation technique appears to be important. Anesthetic techniques based on inhalational anesthetic agents, supplemented by moderate doses of narcotics, are mo re appropriate than high-dose narcotic anesthesia for early extubation protocols. Postoperative sedation with propofol, which has a rapid of fset of action, may be particularly advantageous. Every published inve stigation has concluded that early extubation is safe, feasible, and d esirable. Morbidity and mortality have not been shown to be affected b y early extubation. Anesthetic technique and the patient's medical con dition are the two major factors to consider in accomplishing early ex tubation.