Patients should be extubated in the operating room after routine cardiac surgery: An inconvenient truth

Abstract

Central MessageExtubation in the operating room after routine cardiac surgery is safe and beneficial when facilitated by an aligned multidisciplinary team. Extubation in the operating room after routine cardiac surgery is safe and beneficial when facilitated by an aligned multidisciplinary team. Feature Editor's Introduction—Although 24-hour ventilator times have remained the quality metric for Society for Thoracic Surgeons (STS) Star rankings, it has become apparent over the past several years that the association between vent time and morbidity occurs much earlier.1Crawford T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The reporting of a 6-hour metric for the past 20 years in the STS Adult Cardiac Surgery Database (ACSD) was a recognition of its benefits2Cheng D.C. Karski J. Peniston C. Raveendran G. Asokumar B. Carroll J. et al.Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.Anesthesiology. 1996; 85: 1300-1310Crossref PubMed Scopus (334) Google Scholar and pushed us to earlier extubations, such that ventilation time <6 hours has doubled since 2005, currently being accomplished in >60% of isolated coronary artery bypass grafting (CABG) surgeries (2017-20 ACSD Report).In this month's JTCVS Techniques, Hayanga and colleagues3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar in their expert opinion are now challenging us to improve the quality of care we give our patients by raising the bar even higher to extubate patients before leaving the operating room, an event that currently occurs in fewer than 1 in 20 recipients of isolated CABG, for example (2017-20 ACSD Report).Their opinion that this will be better for our patients stands to reason, as this group has championed operating room (OR) extubations for almost a decade, and they substantiate their prejudice by citing their own experience. The authors point out that their propensity-matched study comparing OR extubations to early intensive care unit (ICU) extubations showed significant decreases in ICU length of stay (3 hours) and postoperative length of stay (1 day), and a cost savings of $8 this should read $800 to $900 per patient. However, this expert opinion, which rests so heavily on this one study, might not sufficiently stress its limitations—that it suffers from being observational, retrospective, single-institutional, and clearly open to the criticism that variables not included in the multivariate analysis could have changed the results. Nevertheless, any of us in programs that perform OR extubations realize that it is applicable to far more than 5% of cardiac patients.I am struck by 3 themes within this opinion piece that I find of particular importance. First, OR extubation in the appropriate patient is safe, and possibly beneficial. Second, the authors' emphasis on the multidisciplinary effort to accomplish the task should be lost on no one. The necessity to work together as a team of surgeons, anesthesiologists, perfusionists, and other, is appropriately highlighted. Finally, as the evidence continues to build that OR extubation in the right patient is an improvement in care, the authors challenge all of us to do more of it and lay out the tenets required to do so, safely. They should be commended. As we have done in the past (eg, with mitral valve repair), multiarterial grafting, transcatheter aortic valve replacements, and now, as trumpeted in this article, OR extubations, cardiac surgery should embrace every effort to improve what we do, regardless of its “inconvenience.”Glenn J. R. Whitman, MD Prolonged intubation for >24 hours after cardiac surgery is associated with poor outcome and increased mortality.4Shahian D.M. Jacobs J.P. Badhwar V. Kurlansky P.A. Furnary A.P. Cleveland Jr., J.C. et al.The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 1-background, design considerations, and model development.Ann Thorac Surg. 2018; 105: 1411-1418Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar This may be largely a function of prolonged exposure to a combination of intravenous paralytics, sedation, and ventilatory support. The utility of wakefulness, active diaphragmatic contraction, and early ambulation have become predominant themes in intensive care applicable to management of the cardiac surgical patient in the immediate postoperative period.1Crawford T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 2Cheng D.C. Karski J. Peniston C. Raveendran G. Asokumar B. Carroll J. et al.Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.Anesthesiology. 1996; 85: 1300-1310Crossref PubMed Scopus (334) Google Scholar, 3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,5Gruther W. Benesch T. Zorn C. Paternostro-Sluga T. Quittan M. Fialka-Moser V. et al.Muscle wasting in intensive care patients: ultrasound observation of the M. quadriceps femoris muscle layer.J Rehabil Med. 2008; 40: 185-189Crossref PubMed Scopus (208) Google Scholar, 6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 7Trouillet J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar “Fast-track” or early extubation has been linked to improved quality and resource utilization. Admittedly, the definition of fast-track may be in the eye of the beholder, and it has been variably defined as endotracheal intubation for <6 to 12 hours postoperatively.2Cheng D.C. Karski J. Peniston C. Raveendran G. Asokumar B. Carroll J. et al.Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.Anesthesiology. 1996; 85: 1300-1310Crossref PubMed Scopus (334) Google Scholar,3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 7Trouillet J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Grant M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The concept of early extubation originally faced considerable resistance when introduced >2 decades ago.7Trouillet J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Early opponents argued that the resultant effects of anesthesia produced too great a burden of hypercarbia and electrolyte imbalance to risk adding the loss of control of the airway to the already precarious equation. Nevertheless, the practice of rapid extubation has gained wide acceptance over the last decade, and it has become a significant enhancement to quality outcomes following cardiac surgery.1Crawford T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 2Cheng D.C. Karski J. Peniston C. Raveendran G. Asokumar B. Carroll J. et al.Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.Anesthesiology. 1996; 85: 1300-1310Crossref PubMed Scopus (334) Google Scholar, 3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 4Shahian D.M. Jacobs J.P. Badhwar V. Kurlansky P.A. Furnary A.P. Cleveland Jr., J.C. et al.The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 1-background, design considerations, and model development.Ann Thorac Surg. 2018; 105: 1411-1418Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 7Trouillet J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Grant M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Simultaneously, sporadic experience with safe extubation in the operating room (OR) following cardiac surgery was applied in a limited manner to off-pump coronary artery bypass grafting and selected operations performed on cardiopulmonary bypass, such as minimally invasive procedures.3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,9Totonchi Z. Azarfarin R. Jafari L. Alizadeh Ghavidel A. Baharestani B. Alizadehasl A. et al.Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: a randomized clinical trial.Anesth Pain Med. 2018; 8: e80158PubMed Google Scholar,10Borracci R.A. Ochoa G. Ingino C.A. Lebus J.M. Grimaldi S.V. Gambetta M.X. Routine operation theatre extubation after cardiac surgery in the elderly.Interact Cardiovasc Thorac Surg. 2016; 22: 627-632Crossref PubMed Scopus (11) Google Scholar This has now been extended to patients following routine cardiac surgery, particularly those without significant coagulopathy and without intraoperative ventilatory or oxygenation aberrations with no anticipated difficulty in the use of mask ventilation or need for urgent reintubation.3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,9Totonchi Z. Azarfarin R. Jafari L. Alizadeh Ghavidel A. Baharestani B. Alizadehasl A. et al.Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: a randomized clinical trial.Anesth Pain Med. 2018; 8: e80158PubMed Google Scholar, 10Borracci R.A. Ochoa G. Ingino C.A. Lebus J.M. Grimaldi S.V. Gambetta M.X. Routine operation theatre extubation after cardiac surgery in the elderly.Interact Cardiovasc Thorac Surg. 2016; 22: 627-632Crossref PubMed Scopus (11) Google Scholar, 11Subramaniam R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar is for safe routine extubation performed in the OR on an of patient outcome to OR extubation following routine cardiac surgery has an of the experience with quality improvement early extubation and a cardiac anesthesia from The Society of Thoracic Surgeons extubation within hours after surgery as a quality of care on on beneficial D.M. Jacobs J.P. Badhwar V. Kurlansky P.A. Furnary A.P. Cleveland Jr., J.C. et al.The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 1-background, design considerations, and model development.Ann Thorac Surg. 2018; 105: 1411-1418Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar The for all early extubation have been on cost resource and with a to D.C. Karski J. Peniston C. Raveendran G. Asokumar B. Carroll J. et al.Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.Anesthesiology. 1996; 85: 1300-1310Crossref PubMed Scopus (334) Google Scholar,3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 7Trouillet J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Grant M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The use of and to fast-track extubation has clearly T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,3Badhwar V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar Nevertheless, have that the 6-hour might not be on as outcomes of and morbidity may not patients have been for T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar a propensity-matched study of extubation after cardiac surgery management OR extubation was to extubation in the intensive care unit (ICU) within hours or 12 and no significant in or V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google the of length of and cost enhanced in those in the OR those within or 12 hours after ICU V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar intubation 12 hours is associated with in and length of T.C. Magruder J.T. Grimm J.C. Sciortino C. Conte J.V. Kim B.S. et al.Early extubation: a proposed new metric.Semin Thorac Cardiovasc Surg. 2016; 28: 290-299Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google J.L. Combes A. Vaissier E. Luyt C.E. Ouattara A. Pavie A. et al.Prolonged mechanical ventilation after cardiac surgery: outcome and predictors.J Thorac Cardiovasc Surg. 2009; 138: 948-953Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar all postoperative be to prolonged the increased risk of and will the in of early A of the of from ventilation has in the of on of to A. T. A. J. et mechanical ventilation for of postoperative a of the of and PubMed Scopus Google Scholar This is largely in with the of diaphragmatic and of the on and of and the of has become an on of and on and the recovery As such as and have in in of their association with time to extubation and ICU length of stay with such as A of the of for PubMed Scopus Google Scholar, G. L. Carroll J. R. V. et reduces after cardiac surgery: a randomized controlled trial.Anesthesiology. 2016; PubMed Scopus Google Scholar, M. C. in adult cardiac surgery and the cardiac surgery intensive care an clinical PubMed Scopus Google Scholar The and of clinical that OR extubation multidisciplinary V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,9Totonchi Z. Azarfarin R. Jafari L. Alizadeh Ghavidel A. Baharestani B. Alizadehasl A. et al.Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: a randomized clinical trial.Anesth Pain Med. 2018; 8: e80158PubMed Google Scholar, 10Borracci R.A. Ochoa G. Ingino C.A. Lebus J.M. Grimaldi S.V. Gambetta M.X. Routine operation theatre extubation after cardiac surgery in the elderly.Interact Cardiovasc Thorac Surg. 2016; 22: 627-632Crossref PubMed Scopus (11) Google Scholar, 11Subramaniam R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar the may be clearly to for more the may be of and sedation, ventilatory and and all in to the R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar and J. M. E. Early extubation without increased in cardiac surgical Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar the utility of the and its to the and team. care may the use of and of the use of with of the of which may as a to to A of the of for PubMed Scopus Google Scholar, G. L. Carroll J. R. V. et reduces after cardiac surgery: a randomized controlled trial.Anesthesiology. 2016; PubMed Scopus Google Scholar, M. C. in adult cardiac surgery and the cardiac surgery intensive care an clinical PubMed Scopus Google Scholar, J. M. E. Early extubation without increased in cardiac surgical Thorac Surg. Full Text Full Text PDF PubMed Scopus Google Scholar The for OR of appropriate patients is of great utility in clinical the and R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar a on and of cardiac as as (eg, OR extubation was as a safe for extubation in the OR following any of adult cardiac R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar is this of evidence that may the of OR to the of intraoperative of from a and muscle has been a and for P. T. B. V. C. et within an enhanced recovery program is associated with and improved patient postoperative after open cardiac controlled Scopus Google S. D. B. S. T. et for in adult cardiac surgical patients: a randomized controlled PubMed Scopus Google Scholar not the of anesthesia may OR extubation following cardiac The and of enhanced recovery after cardiac surgery have a in early extubation and OR extubation V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar has been a in the use of minimally invasive and cardiac surgical are in the of to the of prolonged intubation and length of stay management a is a on of this such as minimally invasive surgical for patients of higher cardiopulmonary bypass OR and are of V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar,10Borracci R.A. Ochoa G. Ingino C.A. Lebus J.M. Grimaldi S.V. Gambetta M.X. Routine operation theatre extubation after cardiac surgery in the elderly.Interact Cardiovasc Thorac Surg. 2016; 22: 627-632Crossref PubMed Scopus (11) Google R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar The of OR extubation the use of minimally invasive the multidisciplinary approach the of a team of OR extubation may be applied to any operation that in a routine manner without coagulopathy or risk of urgent may the use of a as an or an for of of anesthesia a of and of with such as within our this team approach has the of routine OR extubation to the of all adult cardiac operations This operations in patients with and even the or heart when appropriate are and are in and is in the with any being cardiopulmonary bypass, is to with of intravenous and the of to an appropriate and routine are to the to a The patient is to the with the operating room and a surgical and use is for regardless of and minimally invasive are when with are to early postoperative with the of The of early extubation are now Nevertheless, are to the effects of and which may the of a patient with or right The may and a to surgical as as A of OR extubation is following extubation and the to on the of of care, such as the patient to the ICU and a intraoperative the patient is in the it the of the anesthesia and care to and as the patient continues to from when OR extubation and are R. Esper et of operating room extubation in adult cardiac surgery.J Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar the risk of hypercarbia that may right function and may the need for ventilation in the emphasis on a effort is without postoperative care or may in a team approach to OR it is that a without evidence by any of the anesthesiologists, practice and of patient may a to by and as such should be by that to and on V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,6Fitch Z.W. Debesa O. Ohkuma R. Duquaine D. Steppan J. Schneider E.B. et al.A protocol-driven approach to early extubation after heart surgery.J Thorac Cardiovasc Surg. 2014; 147: 1344-1350Abstract Full Text Full Text PDF PubMed Scopus (28) Google M.C. Isada T. Ruzankin P. Whitman G. Lawton J.S. Dodd -O.J. et al.Results from an enhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg. 2020; 159: 1393-1402.e7Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar This approach to the a Routine OR extubation is as much of a team as a for quality improvement in cardiac The of to a with is to OR is the anesthesia care team be to the use of muscle and of and of the to early of of and after the of surgery be and the need for surgical should be to a The may be to extubate in the of the need for and the risk of to a cardiac patient. the ICU team will need to an cardiac surgical patient to the ICU than one is and and postoperative are to V. Esper S. Brooks M. Mulukutla S. Hardison R. Mallios D. et al.Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs.J Thorac Cardiovasc Surg. 2014; 148: 3101-3109.e1Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar OR extubation has been as a the patient to the ICU will become a and will all become aligned with OR extubation and management Finally, and to the their and their will to this of quality care in cardiac Extubation in the OR following routine cardiac surgery be done safely with improved outcomes and enhanced patient This multidisciplinary effort of the and of the the of the OR extubation rests within its on quality and

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