EARLY EXTUBATION FOLLOWING CARDIAC-SURGERY IN A VETERANS POPULATION

Background Early tracheal extubation is an important component of the ''fast track'' cardiac surgery pathway, Factors associated with time t o extubation in the Department of Veterans Affairs (DVA) population ar e unknown. The authors determined associations of preoperative risk an d intraoperative clinical process variables with time to extubation in this population. Methods: Three hundred four consecutive patients und ergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliate DVA medical center were studied retrospecti vely. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regressi on was used to determine associations with tracheal extubation less th an or equal to 10 h (early) or >10 h (late) after surgery. Postoperati ve lengths of stay, complications, and 30-day and 6-month mortality ra tes were compared between the two groups. Results: One hundred forty-s ix patients (48.3%) were extubated early; one patient required emergen t reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intra aortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) (''late'' association is indicated b y an odds ratio >1.00; ''early'' association is indicated by an odds r atio <1.00). Entry of these risk variables into a second regression mo del, followed by univariately significant intraoperative clinical proc ess variables, yielded the following associations (model R-P): age (od ds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-mu g/kg increment), major inotrope use (odds ratio, 5.73), plat elet transfusion (odds ratio, 10.03), use of an arterial graft (odds r atio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-mu g/kg increm ent). Time of arrival in the intensive care unit after surgery was als o significant (odds ratio, 1.42 per 1-h increment), Intraoperative cli nical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test). Conclusions: In this population, early tracheal extubation was accomplished in 48% of patients. Intraop erative clinical process variables are important factors to be conside red in the timing of postoperative extubation after fast track cardiac surgery.