Tiganila Raluca, McCoy Carolyn, Gilbert Robert, Raco James
Human Nutrition and Functional Medicine Program, University of Western States, Portland, OR.
Canadian Society of Respiratory Therapists, Ottawa, ON.
Can J Respir Ther. 2023 Jan 20;59:8-19. doi: 10.29390/cjrt-2022-037. eCollection 2023.
Early extubation (EE), within 8 h of cardiac surgery, is associated with improved resource utilization. Studies have demonstrated that for patients receiving low-dose, fast-track opioid cardiac anesthesia (FTCA) protocols, EE is as safe as conventional care. To date, it is unclear when the earliest timepoints for safe extubation might be. Additionally, some authors pointed out that certain patients receiving FTCA protocols frequently experience delays during extubation attempts. Understanding the factors associated with delayed extubation is crucial for perioperative planning and resource management. This review seeks to 1) determine whether immediate extubation (IE) in the operating room is as safe as EE and 2) identify factors associated with delayed extubation.
MEDLINE, Cochrane Library, EMBASE and CINAHL (up to March 2022) were searched. Studies pertaining to FTCA, IE, EE or factors associated with delayed extubation were included. All authors extracted, appraised and synthesized data. The primary outcome measures were treatment results and factors associated with delayed extubation.
Six studies investigated treatment outcomes associated with FTCA and IE. One randomized controlled trial reported that outcomes associated with IE were comparable to those with EE. Five observational studies reported incidence for 19 treatment outcomes associated with IE, but no comparisons were made to EE. Six observational studies assessed pre- and intraoperative factors associated with delayed extubation in FTCA patients. In at least one study, 37 factors were investigated and 22 were identified. The most frequently reported factors were pre-existing cardiac insufficiency or renal disease, time on pump and cross-clamp time. Obesity and stroke were investigated but were not associated with delayed extubation. No study examined the influence of race, ethnicity or gender on outcomes.
Evidence pertaining to treatment outcomes associated with FTCA and IE is weak. Observational studies cannot determine causation. Large multicentre randomized control trials are required to determine the safety of IE. Although numerous factors have been associated with delayed extubation, several studies do not describe how or which factors were selected for examination. Therefore, certain factors may have yet to be evaluated. Future studies should comprehensively define all factors under investigation.
心脏手术后8小时内进行早期拔管（EE）与资源利用的改善相关。研究表明，对于接受低剂量、快速通道阿片类心脏麻醉（FTCA）方案的患者，EE与传统护理一样安全。迄今为止，尚不清楚安全拔管的最早时间点可能是什么时候。此外，一些作者指出，某些接受FTCA方案的患者在拔管尝试过程中经常出现延迟。了解与延迟拔管相关的因素对于围手术期规划和资源管理至关重要。本综述旨在1）确定手术室即时拔管（IE）是否与EE一样安全，以及2）识别与延迟拔管相关的因素。
检索了MEDLINE、Cochrane图书馆、EMBASE和CINAHL（截至2022年3月）。纳入了与FTCA、IE、EE或与延迟拔管相关因素的研究。所有作者提取、评估和综合数据。主要结局指标是治疗结果和与延迟拔管相关的因素。
六项研究调查了与FTCA和IE相关的治疗结果。一项随机对照试验报告称，与IE相关的结果与EE相当。五项观察性研究报告了与IE相关的19种治疗结果的发生率，但未与EE进行比较。六项观察性研究评估了FTCA患者延迟拔管的术前和术中因素。在至少一项研究中，调查了37个因素，确定了22个因素。最常报告的因素是既往存在的心脏功能不全或肾脏疾病、体外循环时间和主动脉阻断时间。对肥胖和中风进行了调查，但它们与延迟拔管无关。没有研究考察种族、民族或性别对结局的影响。
与FTCA和IE相关的治疗结果证据不足。观察性研究无法确定因果关系。需要大型多中心随机对照试验来确定IE的安全性。尽管有许多因素与延迟拔管相关，但一些研究没有描述如何或选择了哪些因素进行检查。因此，某些因素可能尚未得到评估。未来的研究应全面定义所有研究中的因素。
