Removal of the tube that allows mechanical breathing support after cardiac surgery in adults may safely reduce stay in intensive care

Hawkes CA, Dhileepan S, Foxcroft DR

Published Online:

April 18, 2012

Historically, adult cardiac surgical patients needed mechanical breathing support overnight after surgery. Results from six controlled trials showed that earlier removal of the tube that ensures open airways and allows mechanical breathing support, within eight hours of skin closure after surgery, reduces intensive care length of stay, and possibly hospital length of stay, with no evidence of an increase in the risk of harmful effects or death.

Abstract (click to read)

Background:

Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays.

Objectives:

To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE (January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field.

Selection criteria:

Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair).

Data collection and analysis:

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted.

Main results:

Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively).

Authors' conclusions:

There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups.

Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.

This record should be cited as:

Hawkes CA, Dhileepan S, Foxcroft DR. Early extubation for adult cardiac surgical patients. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003587. DOI: 10.1002/14651858.CD003587

Assessed as up to date:

June 27, 2003

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Primary Review Group:

Anaesthesia Group

Health topics:

Anaesthesia & pain control > Anaesthesia & medical diseases > Peri-operative events

Anaesthesia & pain control > Peri-anaesthetic/peri-operative care > Peri-operative management of the anaesthetic patient

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Removal of the tube that allows mechanical breathing support after cardiac surgery in adults may safely reduce stay in intensive care

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