Timing of tracheal extubation in adult cardiac surgery patients

In this article, we examine 14 studies conducted from 1974 to 1994 on "early" endotracheal extubation (0 to 12 hours postoperatively) in adult cardiac surgery patients. Aspects reviewed include: criteria for patient selection; criteria for extubation; analyses of feasibility and safety; effects of anesthetic technique; and patient morbidity. Advantages and disadvantages of early or "fast-track" extubation are discussed as are directions for future research. Selection criteria varied among studies; patients were most commonly excluded because of severe, preexisting pulmonary disease or ventricular dysfunction. Based on the studies examined, however, at least 70% to 80% of adult patients would meet selection criteria. Three universal criteria were applied in all studies: (1) patient is awake and responsive; (2) adequate gas exchange while breathing spontaneously; and (3) cardiovascular stability. To facilitate early extubation in appropriately selected patients, the choice of anesthetic technique and postoperative sedation technique appears to be important. Anesthetic techniques based on inhalational anesthetic agents, supplemented by moderate doses of narcotics, are more appropriate than high-dose narcotic anesthesia for early extubation protocols. Postoperative sedation with propofol, which has a rapid offset of action, may be particularly advantageous. Every published investigation has concluded that early extubation is safe, feasible, and desirable. Morbidity and mortality have not been shown to be affected by early extubation. Anesthetic technique and the patient's medical condition are the two major factors to consider in accomplishing early extubation.