Department of Anesthesia, Lankenau Hospital, Lankenau Institute of Medical Research, Wynnewood, PA, USA.
J Cardiothorac Vasc Anesth. 2010 Oct;24(5):780-4. doi: 10.1053/j.jvca.2010.04.002. Epub 2010 Jul 22.
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.
A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data.
Three interrelated, university-affiliated, community hospitals.
Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006.
Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit.
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.
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.
确定在心脏手术后于手术室行气管拔管是否与重症监护病房（ICU）和医院的住院时间相关。
一项非随机、观察性研究，采用倾向评分指导的前瞻性收集数据病例对照匹配。
三家相互关联的大学附属社区医院。
2000 年至 2006 年间行择期或急症冠状动脉、瓣膜修复或置换或联合手术的 3317 例患者。
根据病史和术中事件，患者在手术室或 ICU 中拔管。
在机构胸外科医师学会数据库的 3317 例患者中，3089 例患者在 24 小时内拔管，其中 69%在手术室拔管。仅 0.6%在手术室拔管的患者需要重新插管，而在 ICU 拔管的患者中有 5.9%需要重新插管（p<0.0001）。通过逻辑回归，在 25 个术前和术中因素中，对 2595 例具有完整数据的患者中的每一个患者生成了一个倾向性评分，代表即刻拔管的可能性（C 统计量=0.727）。采用“贪婪 5 比 1”倾向评分匹配技术，通过拔管途径创建了 713 对匹配的患者。与在 ICU 中延长 23 小时相比，即刻拔管的患者 ICU 持续时间平均减少（中位数从 46 小时减少到 27 小时，p<0.0001），住院时间平均减少 0.8 天（中位数为每例 6 天，p<0.0001）。使用匹配对作为分层的 Cox 回归，确定 ICU 和医院住院时间的独立预测因素包括：在手术室即刻拔管、需要重新插管、术后肾衰竭和术后心房颤动。
经验丰富的临床医生选择患者即刻在手术室拔管与 ICU 和医院住院时间缩短相关。即刻拔管很少导致气管重新插管。
