The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.

OBJECTIVE

To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery.

DESIGN

A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data.

SETTING

Three interrelated, university-affiliated, community hospitals.

PARTICIPANTS

Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006.

INTERVENTIONS

Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit.

MEASUREMENTS AND MAIN RESULTS

Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A "greedy 5 to 1" propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation.

CONCLUSIONS

Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.