London M J, Shroyer A L, Coll J R, MaWhinney S, Fullerton D A, Hammermeister K E, Grover F L
University of Colorado Health Sciences Center/Denver Veterans Affairs Medical Center, 80220, USA.
Anesthesiology. 1998 Jun;88(6):1447-58. doi: 10.1097/00000542-199806000-00006.
Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population.
Three hundred four consecutive patients undergoing 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-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation < or = 10 h (early) or > 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups.
One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intraaortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-microg/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-microg/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test).
In this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery.
早期气管拔管是“快速通道”心脏手术流程的重要组成部分。退伍军人事务部（DVA）人群中与拔管时间相关的因素尚不清楚。作者确定了该人群术前风险和术中临床过程变量与拔管时间的关联。
回顾性研究了1993年10月1日至1995年9月30日在一所大学附属DVA医疗中心接受冠状动脉搭桥术、瓣膜手术或两者兼有的304例连续患者，这些患者均采用快速通道临床路径。在对一系列术前风险和术中临床过程变量进行单变量筛选后，采用逐步逻辑回归确定与术后气管拔管≤10小时（早期）或>10小时（晚期）的关联。比较两组患者的术后住院时间、并发症以及30天和6个月死亡率。
146例患者（48.3%）早期拔管；1例患者需要紧急重新插管（0.7%）。在考虑的术前风险变量中，只有年龄（每增加10岁比值比为1.80）和术前主动脉内球囊反搏（比值比为7.88）与拔管时间多变量相关（模型R）（比值比>1.00表示“晚期”关联；比值比<1.00表示“早期”关联）。将这些风险变量纳入第二个回归模型，随后纳入单变量有显著意义的术中临床过程变量，得出以下关联（模型R-P）：年龄（每增加10岁比值比为1.86）、舒芬太尼剂量（每增加1μg/kg比值比为1.54）、使用主要血管活性药物（比值比为5.73）、血小板输注（比值比为10.03）、使用动脉移植物（比值比为0.32）以及芬太尼剂量（每增加10μg/kg比值比为1.45）。术后进入重症监护病房的时间也具有显著意义（每增加1小时比值比为1.42）。术中临床过程变量显著提高了模型性能（似然比检验P<0.001）。
在该人群中，48%的患者实现了早期气管拔管。术中临床过程变量是快速通道心脏手术后决定术后拔管时机时需要考虑的重要因素。
