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Published on: May 26, 2023
Operating Room Extubation After Cardiac Surgery: A Promising Practice, or a Product of Selection Bias?
Chelsea J Messinger1, Elizabeth Hall1, Matthew R Smith1
1Division of Cardiac Anesthesia, Department of Anesthesiology, Massachusetts General Hospital, Mass General Brigham, Boston, MA.
Objectives:
To evaluate the feasibility, safety, and early outcomes of a standardized operating room extubation (ORE) protocol implemented for elective cardiac surgery patients requiring cardiopulmonary bypass.
Design:
A prospective observational cohort study with systematic protocol implementation and data collection.
Setting:
A single academic medical center.
Participants:
Six hundred twenty-eight patients undergoing elective cardiac surgery with cardiopulmonary bypass between November 2024 and June 2025.
Interventions:
Implementation of a protocol requiring systematic consideration of ORE for all eligible patients, with 171 patients (27%) receiving ORE and 457 patients receiving conventional intensive care unit (ICU) extubation.
Measurements And Main Results:
Primary outcomes included unadjusted ORE utilization rates, reintubation rates, 30-day mortality, ICU length of stay, and hospital length of stay. On average 28% of eligible cases were extubated each month. Patients selected for ORE were relatively young (median age 62 years) with a low comorbidity burden. All ORE patients survived for 30 days. Reintubation occurred in 5 patients (2.9%). Median ICU stay was shorter for ORE patients compared with the overall cohort (26 v 38 hours), while median hospital stay was similar between groups (5 days).
Conclusions:
A standardized ORE protocol demonstrated feasibility and safety in selected cardiac surgery patients, with low reintubation rates, zero 30-day mortality, and reduced ICU length of stay. However, these encouraging outcomes likely reflect patient selection based on clinical judgment and cannot establish comparative efficacy relative to early ICU extubation. A multicenter randomized controlled trial is needed to determine efficacy and define optimal patient populations for ORE.
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