Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
Ann Thorac Surg. 2022 Jun;113(6):2027-2035. doi: 10.1016/j.athoracsur.2021.06.060. Epub 2021 Jul 27.
Reintubation and prolonged intubation after cardiac surgery are associated with significant complications. Despite these competing risks, providers frequently extubate patients with limited insight into the risk of reintubation at the time of extubation. Achieving timely, successful extubation remains a significant clinical challenge.
Based on an analysis of 2835 patients undergoing cardiac surgery at our institution between November 2017 and July 2020, we developed a model for an individual's risk of reintubation at the time of extubation. Predictors were screened for inclusion in the model based on clinical plausibility and availability at the time of extubation. Rigorous data reduction methods were used to create a model that could be easily integrated into clinical workflow at the time of extubation.
In total, 90 patients (3.2%) were reintubated within 48 hours of initial extubation. Number of inotropes (1 [adjusted odds ratio (OR), 15.4; 95% confidence interval (CI) 6.5-47.6; P < .001], ≥2 [OR, 62.7; 95% CI 14.3-279.5; P < .001]); dexmedetomidine dose (OR, 3.0 [per μg/kg/h]; 95% CI 1.9-4.7; P < .001), time to extubation (OR, 1.04 [per 6-hour increase]; 95% CI 1.02-1.05; P < .001), and respiratory rate (OR, 1.04 [per breath/min]; 95% CI 1.01-1.07; P < .001) were the best predictors for the model, which displayed excellent discriminative capacity (area under the receiver operating characteristic, 0.86; 95% CI 0.84-0.89).
An improved understanding of reintubation risk may lead to improved decision-making at extubation and targeted interventions to decrease reintubation in high-risk patients. Future studies are needed to optimize timing of extubation.
心脏手术后重新插管和长时间插管与严重并发症有关。尽管存在这些相互竞争的风险，但在拔管时，医护人员经常在对拔管后重新插管风险缺乏了解的情况下拔管。实现及时、成功的拔管仍然是一个重大的临床挑战。
基于对 2017 年 11 月至 2020 年 7 月在我院接受心脏手术的 2835 例患者的分析，我们建立了一个在拔管时评估患者重新插管风险的模型。根据临床合理性和拔管时的可用性，对预测因素进行筛选，以纳入模型。使用严格的数据简化方法创建了一个可在拔管时轻松集成到临床工作流程中的模型。
共有 90 例（3.2%）患者在初始拔管后 48 小时内再次插管。使用的正性肌力药物的数量（1 [调整后比值比（OR），15.4；95%置信区间（CI）6.5-47.6；P <.001]，≥2 [OR，62.7；95% CI 14.3-279.5；P <.001]）；右美托咪定剂量（OR，3.0 [每μg/kg/h]；95% CI 1.9-4.7；P <.001），拔管时间（OR，1.04 [每 6 小时增加 1 秒]；95% CI 1.02-1.05；P <.001）和呼吸频率（OR，1.04 [每呼吸/分钟增加 1 次]；95% CI 1.01-1.07；P <.001）是该模型的最佳预测因素，该模型具有出色的鉴别能力（接受者操作特征曲线下面积，0.86；95% CI 0.84-0.89）。
对重新插管风险的深入了解可能会导致在拔管时做出更好的决策，并针对高危患者采取有针对性的干预措施来降低重新插管的风险。需要进一步的研究来优化拔管时机。
