ADULT CARDIAC
CARDIOTHORACIC ANESTHESIOLOGY:
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Multidisciplinary Extubation Protocol in Cardiac
Surgical Patients Reduces Ventilation Time and
Length of Stay in the Intensive Care Unit
Matthew E. Cove, MBChB, Chen Ying, BS, Juvel M. Taculod, RRT-NPS,
Siow Eng Oon, RN, Pauline Oh, RN, Ramanathan Kollengode, MBBS,
Graeme MacLaren, MBBS,* and Chuen Seng Tan, PhD*
Cardiothoracic Intensive Care Unit, Department of Cardiothoracic and Vascular Surgery, and Division of Respiratory Medicine and
Critical Care, Department of Medicine, National University Hospital, and Saw Swee Hock School of Public Health, National University
of Singapore, Singapore
Background. Protocolized care bundles may improve
patient care by reducing medical errors, minimizing
practice variability, and reducing mortality. We hypoth-
esized that the introduction of a multidisciplinary extu-
bation protocol would reduce duration of mechanical
ventilation and intensive care unit length of stay in a
tertiary cardiothoracic intensive care unit.
Methods. A multidisciplinary extubation protocol was
created. The protocol was applied to all elective post-
operative cardiac surgery patients. Data were collected 3
months before and 3 months after protocol initiation.
Patients were excluded if they experienced events that
contraindicated application of the protocol.
Results. Two hundred one patients undergoing elec-
tive open cardiac surgery were included: 99 patients
before protocol implementation (preprotocol) and 102
I ntensive care units (ICUs) are challenging, fast-paced
environments, in which health care teams are
constantly responding to new information and urgent
problems [1]. Such environments are prone to errors of
commission and failures of omission [2–6] as staff are
constantly distracted [7]. Physicians are particularly prone;
conflicting demands, long hours, and a need to focus on
the most unstable patients can distract them from simple
decisions that substantially affect patient care [6]. For
example, timely removal of invasive devices may often be
overlooked, but appropriate early device removal reduces
device-related infection rates by up to 50% [8, 9].
In the ICU, delayed extubation increases the risk of
ventilator-acquired pneumonia [10], prolongs the use of
Accepted for publication Feb 16, 2016.
*Graeme MacLaren and Chuen Seng Tan contributed equally to this
work.
Address correspondence to Dr Cove, Division of Respiratory Medicine
and Critical Care, Department of Medicine, National University Hospital,
NUHS Tower Block Level 10, 1E Kent Ridge Rd, Singapore 119228; email:
mdcmec@nus.edu.sg.
Ó 2016 by The Society of Thoracic Surgeons
Published by Elsevier
patients after implementation (postprotocol). Median
extubation time was reduced by 35% (620 minutes versus
405 minutes; p < 0.001), whereas adjusted extubation time
remained significantly reduced by 144 minutes (p < 0.001).
Intensive care unit length of stay was reduced from 2
days preprotocol to 1 day postprotocol (p < 0.001). Rein-
tubation rate was the same in both groups (2.06% versus
1.96%; p [ 1.0).
Conclusions. A simple multidisciplinary extubation
protocol is safe and associated with a significant reduc-
tion in the duration of mechanical ventilation and
intensive care unit length of stay after elective cardiac
surgery.
(Ann Thorac Surg 2016;102:28–34)
Ó 2016 by The Society of Thoracic Surgeons
sedative medication [11, 12], delays rehabilitation [13],
and increases cost [14, 15]. In contrast, early extubation (4
to 6 hours) after cardiac surgery results in shorter ICU
stays and lower overall costs [16]. Consequently, post-
operative ventilation exceeding 24 hours is an important
performance measure published by the National Quality
Forum in the United States [17]. The opportunity
to perform early extubation is frequently missed; it
was recently reported that as few as 12% of cardiac
surgery patients are extubated within 6 hours [18].
However, standardized protocols can more than double
the number of patients achieving extubation within 6 to
8 hours [18, 19].
In our ICU, we recently implemented a multidisci-
plinary extubation protocol. It was designed to ensure
suitable postoperative patients were safely prepared for
extubation, regardless of how busy or distracted ICU
The Appendices can be viewed in the online version of
this article [http://dx.doi.org/10.1016/j.athoracsur.2016.
02.071] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2016.02.071
Ann Thorac Surg
2016;102:28–34
physicians were. We hypothesized that a team-based
protocol would reduce time to extubation and that this
would translate into reduced length of stay in the ICU.
Material and Methods
Extubation Protocol
In December 2013, the Cardiothoracic ICU at National
University Hospital, Singapore, a 19-bed ICU in a tertiary
academic referral center, introduced an extubation pro-
tocol (Appendix A). Before implementation, bedside
physicians would initiate a spontaneous breathing trial
and decide when to extubate. The extubation protocol
aimed to empower nurses and respiratory therapists to
autonomously initiate sedation and ventilator weaning
and standardize spontaneous breathing trial practices
(Fig 1). Initial ICU ventilator settings were not defined in
the protocol because all postoperative patients are placed
on volume control, synchronous intermittent mandatory
ventilation with a set tidal volume of 8 mL/kg of ideal
body weight, pressure support of 10 cm H2O, positive
end-expiratory pressure of 5 cm H2O, and fraction of
inspired oxygen of 0.8, which is then titrated for oxygen
saturations of 96% or greater, using an existing care
pathway. All patients are ventilated with a Puritan Ben-
nett 840 ventilator (Covidian, Boulder, CO), and neuro-
muscular blockade is not routinely reversed in the
operating room or ICU. During the study period,
cardiothoracic anesthesia guidelines were not changed or
modified.
All elective cardiac surgery patients were eligible for
protocolized extubation unless they had a clinical reason
for exclusion (Fig 1). Protocolized extubation empowered
the nurse to wean sedation and analgesia (intravenous
propofol and morphine) by reducing the dose in half and
then removing the infusion completely if the patient
awoke comfortably. Tramadol and paracetamol were
administered before initiating sedation weaning. Nursing
staff would judge readiness for a spontaneous breathing
trial within 4 to 6 hours of arrival in the ICU. The respi-
ratory therapist would then initiate a spontaneous
breathing trial and, with the presence of ICU physicians,
determine readiness to extubate after 30 minutes (Fig 1).
To measure the impact of the protocol on extubation
practices, we conducted a retrospective before and after
observation study for 3 months before and after protocol
implementation. Following approval from Singapore’s
ethical review board to collect data with a waiver of
consent (NHG DSRB 2014/00596), we obtained data from
all postoperative elective cardiac surgery patients older
than 21 years who were admitted to our ICU. Patients
were excluded if they were not eligible for the extubation
protocol (Fig 1) or were readmitted to ICU during the
same hospitalization. The data collected included age,
sex, logistic European System for Cardiac Operative Risk
Evaluation (EuroSCORE) [20], cardiopulmonary bypass
time, airway assessment, ICU admission time, admission
ventilator settings, time of extubation, inotropic agent
use, admission blood gases, ICU discharge date, and ICU
COVE ET AL 29
SIMPLE PROTOCOL REDUCES EXTUBATION TIME
ADULT CARDIAC
complications, such as reintubation. Data for December
were excluded because protocol implementation
occurred during this month. The nurse-to-patient ratio
was 1:1 and respiratory therapist-to-patient ratio was 1:15
throughout the observational period. Daytime physician
coverage included 3 fellows and a dedicated consultant-
intensivist, whereas overnight, 2 fellows were present
with an on-call consultant off-site.
Statistical Analysis
Our primary outcome measure was time taken to extu-
bate a patient after arrival to the ICU. Mean or median
was calculated for continuous variables with standard
deviation or interquartile range, reported when appro-
priate. For continuous outcomes, unpaired Student’s t test
or Mann-Whitney U test were used to assess for differ-
ences in parametric and nonparametric data, respectively.
For categorical variables, odds ratios and their 95% con-
fidence intervals were reported, and differences were
assessed using Fisher’s exact test.
To account for potential covariates, we performed
multiple linear regression on extubation time and dura-
tion of pressure support, and multiple Poisson regression
on ICU length of stay using complete cases. Three
multivariate models were created. Model 1 used an
agnostic approach to determine the covariates included in
the model, performing forward variable selection with the
likelihood ratio test to add covariates one at a time. At
each variable selection step, the most significant covariate
that was not in the current model was added if its prob-
ability value was at least 0.05. No further covariates were
added if the remaining covariates had probability values
greater than 0.05. Model 2 used prior knowledge,
including covariates known to be associated with the
outcome; logistic EuroSCORE, age, type of surgical pro-
cedure, pH, partial pressure of carbon dioxide, and
lactate. Model 3 included all covariates in models 1 and 2
and represents a sensitivity analysis to ensure the
robustness of model 1 and 2 findings.
To improve the normality assumption for multiple linear
regression, extubation time and duration of pressure sup-
port were logarithmically transformed. For length of stay
in ICU, which is a count variable with no zeros, a Poisson
regression was performed on the length of stay in ICU
excluding the first day of stay. Although the estimated
effect is a ratio for the three outcomes (Appendix B), we
reported the estimated change in minutes or days, to
facilitate interpretation, by multiplying median quantity
before intervention by the estimated percentage change.
When applicable, modifiers on the intervention were
assessed by including the interaction terms into the model.
A probability value of less than 0.05 was considered
significant. Analysis was performed using R software
version 3.1.1 (R-Foundation, Vienna, Austria).
Results
During the preprotocol period, 128 patients were
admitted to the ICU after cardiac surgery, of which 99 met
extubation protocol criteria. During the postprotocol
 30 COVE ET AL
SIMPLE PROTOCOL REDUCES EXTUBATION TIME
ADULT CARDIAC
Fig 1. Extubation protocol flow dia-
gram. (A ¼ adrenaline; CABG ¼
coronary artery bypass grafting;
FIO2 ¼ fraction of inspired oxygen;
NA ¼ noradrenaline; PaO2 ¼ arterial
partial pressure of oxygen; PEEP ¼
positive end-expiratory pressure;
RT ¼ respiratory therapist; SaO2 ¼
arterial saturation of oxygen; SBT ¼
spontaneous breathing trial.)
period, 168 were admitted, with 102 meeting protocol
criteria. Descriptive statistics are presented in Table 1.
There were significantly more Malay participants and
fewer Indian participants in the postprotocol group.
Median pH was slightly lower on arrival to the ICU in the
preprotocol group, and median partial pressure of carbon
dioxide levels were slightly higher (7.37 versus 7.40;
p < 0.001; and 40 versus 39 mm Hg; p ¼ 0.01, respectively).
Lactate was lower in the postprotocol group (2.20 versus
3.56 mmol/L; p < 0.001). Quality-related events occurred
more often in the preprotocol group, but this difference
was not significant. However, significantly more patients
in the preprotocol group received an intraaortic balloon
pump (9 versus 2; p ¼ 0.031), although the proportion of
patients requiring interventions for hypotension did not
significantly differ (32.32% versus 22.6%; p ¼ 0.154). Pa-
tients receiving an intraaortic balloon pump had a higher
median lactate than those without an intraaortic balloon
pump (2.6 versus 3.5 mmol/L), but this difference was not
statistically significant. The remaining characteristics
were similar in both groups.
Unadjusted median extubation time was reduced by
35% after implementation of the protocol (620 versus 405
minutes; p < 0.001). Excluding patients receiving an
intraaortic balloon pump did not greatly change this
observation (Table 2). When adjusted for covariates from
models 1 and 2 (ie, model 3), extubation time was reduced
Ann Thorac Surg
2016;102:28–34
by 144 minutes (95% confidence interval, 70 to 209 mi-
nutes) compared with the preprotocol group (Table 3).
Similarly, unadjusted median time spent on pressure
support was reduced by 24% in the postprotocol group
(130 versus 98 minutes; p < 0.001), which remained sig-
nificant after adjustment (Table 3, model 3). Median ICU
length of stay was reduced from 2 days to 1 day (p <
0.001), and remained significant after adjusting for con-
founding factors in model 3 (Table 3). Modifiers including
low pH and ICU admission after-hours were assessed in
the model. Although the interaction effects were not
significant (Appendix B, Table 1), protocolized extubation
had more impact in patients arriving out of hours, and
less impact when patients arrived with low pH values
(Table 3). The reintubation rate was unaffected, with 2
patients requiring reintubation in both groups (odds ra-
tio, 1.03; 95% confidence interval, 0.07 to 14.48; p ¼ 1).
Both patients in the postprotocol group were reintubated
more than 5 days after extubation; in the preprotocol
group both reintubations occurred within 12 hours.
Comment
In this study we show that the introduction of a simple
extubation protocol into the cardiothoracic ICU is
associated with a 35% reduction in time to extubation,
(620 versus 405 minutes) and a reduction in length of
Ann Thorac Surg COVE ET AL 31
2016;102:28–34 SIMPLE PROTOCOL REDUCES EXTUBATION TIME

ADULT CARDIAC
Table 1. Demographic and Descriptive Statistics
Preprotocol Postprotocol Mean, Median Two-Sided
Variable (n ¼ 99) (n ¼ 102) Difference/OR (95%) p Value

Median age, y (IQR) 60 (55, 68) 60 (54, 69) 0 (3, 3) 0.901

Median EuroSCOREa (IQR) 2.54 (1.51, 4.38) 2.28 (1.42, 4.69) 0.16 (0.67, 0.35) 0.489
Potential difficult airway (%) 11 (11.11) 10 (9.8) 1.15 (0.42, 3.18) 0.82
Quality-related eventsb (%) 18 (18.18) 11 (10.78) 0.59 (0.30, 1.19) 0.162
Sex (%)
Female 20 (20.2) 21 (20.59) 1.02 (0.49, 2.16) 1
Racea (%)
Chinese 62 (63.27) 63 (61.76) . 0.018c
Malay 13 (13.27) 26 (25.49) 1.96 (0.88, 4.56) 0.097
Indian 16 (16.33) 5 (4.9) 0.31 (0.08, 0.96) 0.032
Others 7 (7.14) 8 (7.84) 1.12 (0.33, 3.88) 1
Number of participants (%)
Intraaortic balloon pump 9 (9.09) 2 (1.96) 0.2 (0.021, 1.01) 0.031
Hypotension 32 (32.32) 23 (22.55) 0.61 (0.31, 1.19) 0.154
Reintubationa 2 (2.06) 2 (1.96) 0.95 (0.068, 13.349) 1
Acidosis
Median pHd (IQR) 7.37 (7.33, 7.41) 7.40 (7.36, 7.43) 0.03 (0.013, 0.05) <0.001
Median PCO2,d mm Hg (IQR) 40 (38, 44) 39 (36.1, 42) 2 (3, 0.4) 0.01
Median lactate,a,d mmol/L (IQR) 3.56 (1.90, 5.90) 2.20 (1.40, 3.90) 1 (1.8, 0.48) <0.001
Arrival time to ICU (%)
Between 9 AM and 4:59 PM 56 (56.57) 66 (64.71) . .
Between 5 PM and 8:59 AM 43 (43.43) 36 (35.29) 0.71 (0.39, 1.30) 0.21
Procedurea (%)
Valve surgery onlye 21 (21.21) 19 (18.81) . 0.435c
Bypass surgery with 1–2 vessels 16 (16.16) 24 (23.76) 1.65 (0.66, 4.42) 0.37
(w/out valve surgery)
Bypass surgery with 3 vessels 62 (62.63) 58 (57.43) 1.03 (0.48, 2.26) 1
(w/out valve surgery)
a b
There are some missing values. Reoperation, bleeding, tamponade, bronchospasm, renal replacement therapy, respiratory acidosis,
c d e
death. Fisher’s exact test was performed. Values taken on ICU arrival. Includes aortic, mitral, and tricuspid valve replacement or repair,
or any combination.
EuroSCORE ¼ European System for Cardiac Operative Risk Evaluation; ICU ¼ intensive care unit; IQR ¼ interquartile range; OR ¼ odds
ratio; PCO2 ¼ partial pressure of carbon dioxide.

ICU stay of 1 day. Early extubation is desirable in pa-
tients undergoing elective cardiac surgery as it reduces
elective cancellations, ICU length of stay, and cost by as
much as 25% [21]. As early as the 1970s, physicians
explored early ventilator weaning after cardiac surgery
[22], but there was little interest during the 1980s
because of the popularity of opioid-based anesthesia,
which necessitated prolonged postoperative ventilation
[16]. However, by the 1990s frequent interruptions to
surgical schedules, resulting from a lack of available
ICU beds, prompted surgical teams to revisit early
extubation.

Table 2. Summary Statistics for Main Outcome Measures, Including and Excluding Patients With Intraaortic Balloon Pumps
Variable Preprotocol Postprotocol p Values

Median time to extubation, min (IQR) 620 (395, 925) 405 (323, 571) <0.001
Median time on pressure support,a min (IQR) 130 (95, 220) 105 (80, 157) 0.015
Median number of days in ICUb (reported range) 2 (1, 8) 1 (1, 2) <0.001
IABP patients excluded
Median time to extubation, min (IQR) 605 (385, 915) 403 (321, 574) <0.001
Median time on pressure support,a min (IQR) 130 (93, 210) 105 (80, 155) 0.053
Median number of days in ICUb (IQR) 2 (1, 8) 1 (1, 2) <0.001
a b
There is 1 missing value in the postprotocol group. There are 3 missing values in the preprotocol group and 2 in the postprotocol group.
IABP ¼ intraaortic balloon pump; ICU ¼ intensive care unit; IQR ¼ interquartile range.
 32 COVE ET AL Ann Thorac Surg
SIMPLE PROTOCOL REDUCES EXTUBATION TIME 2016;102:28–34
ADULT CARDIAC

Table 3. Unadjusted and Adjusted Effect of the Protocol on Log Transformed Minutes to Extubation, Minutes on Pressure Support,
and Length of Stay in the Intensive Care Unita
Variable Unadjusted Model 1 Model 2b Model 3c

Minutes to extubationd
Reduction in minutes (95% CI) 186 (116 to 246) 157 (87 to 218) 152 (78 to 216) 144 (70 to 209)
p < 0.001 p < 0.001 p < 0.001 p < 0.001
Minutes on pressure supportc
Reduction in minutes (95% CI) 28 (1 to 49) 27 (0 to 48) 31 (3 to 53) 31 (3 to 52)
p ¼ 0.047 p ¼ 0.051 p ¼ 0.032 p ¼ 0.034
Number of days in CTICUe
Reduction in days (95% CI) 1.62 (1.28 to 1.8) 1.55 (1.13 to 1.77) 1.56 (1.15 to 1.77) 1.54 (1.11 to 1.76)
p < 0.001 p < 0.001 p < 0.001 p < 0.001
Including interaction effect between protocol status and arrival time to CTICU, and between protocol status and pH status for minutes
to extubation
If arrival time is normal work hours and arrival . 78 (204 to 264) 139 (59 to 208) 34 (272 to 235)
pH is normal (95% CI) p ¼ 0.529 p ¼ 0.002 p ¼ 0.794
If arrival time is out of normal hours and arrival . 129 (32 to 209) . 105 (0 to 191)
pH is normal (95% CI) p ¼ 0.012 p ¼ 0.051
If arrival time is normal work hours and arrival . 214 (153 to 407) 259 (36 to 397) 207 (162 to 401)
pH is low (95% CI) p ¼ 0.199 p ¼ 0.029 p ¼ 0.214
If arrival time is out of normal work hours and . 252 (12 to 397) . 256 (23 to 399)
arrival pH is low (95% CI) p ¼ 0.043 p ¼ 0.037
a
Median time before intervention has been multiplied by the estimated percentage reduction, and its 95% confidence interval (CI), to provide reduction in
b c
minutes and days. Model 2 includes logistic EuroSCORE, age, type of surgical procedure, pH, PCO2, and lactate. Model 1 includes age and low
d
blood pressure status, identified by the forward selection; model 3 includes variables from models 1 and 2. Model 1 includes low blood pressure
e
status, arrival time, pH, by the forward selection method; model 3 includes variables from models 1 and 2. Day 0 was excluded and then a Poisson
regression was performed. Model 1 includes IABP, and categorized lactate values, by the forward selection method; model 3 includes variables from
models 1 and 2.
CI ¼ confidence interval; CTICU ¼ cardiothoracic intensive care unit; PCO2 ¼ partial pressure of carbon dioxide.

In 1993, Westaby and colleagues [23] published their
experience of extubating carefully selected patients in a
postoperative recovery area. They demonstrated these
patients could be safely extubated within 2 to 3 hours and
discharged directly to a postoperative ward. Subse-
quently, the term “fast-track cardiac surgery” was quickly
adopted, describing a short postoperative ICU stay of less
than 1 day in which extubation occurs within 4 hours of
surgery. Fast-track protocols require significant workflow
changes. In particular, anesthesia needs to be adjusted,
relying less on high-dose opioid techniques [24] and
keeping intraoperative patient temperatures greater than
32 C [23].
Implementation of protocols that direct intraoperative
management, as well as ICU management, can be chal-
lenging, especially where anesthesia and ICU teams
function independently. Implementation of our protocol
was relatively simple because we designed an ICU-
centric protocol that only directs care after the patient is
admitted to the ICU, which is distinct from existing fast-
track approaches because no intraoperative changes
were necessary.
Our protocol appears safe because there was no effect
on reintubation rates, which aligns with previous studies
of both fast-track protocols and ventilator weaning pro-
tocols in general ICUs [16, 18, 25–27]. It is arguable our
reintubation rate is too low, but a large safety margin is
necessary because our consultant intensivist coverage, as
well as consultant surgical coverage, is off-site after
hours.
We also observed a reduction in length of ICU stay, but
it is not entirely clear why a reduction of median extu-
bation time from 620 to 405 minutes would be associated
with a reduction in length of stay by 1 day. Previous
studies of ICU-centric interventions, mostly conducted in
general ICUs, have a variable impact on length of stay,
with several showing no change [28, 29] leading some
authors to conclude weaning protocols are unnecessary
[30] and may prolong weaning [31]. In contrast to general
ICU settings, postoperative cardiac surgery patients are
more homogeneous and usually not in respiratory failure
when placed on mechanical ventilation. This may partly
explain our observed effect on shortened length of stay,
and reduced extubation times have been associated with
shorter ICU length of stay in other studies focusing on
cardiac surgery patients [27, 32, 33].
The observed reduction in length of stay may be a
consequence of workflow patterns in our cardiothoracic
ICU, where more than a third of admissions occurred
after 5 PM (Table 1). A median extubation time of 620
minutes (>10 hours) suggests many patients were not
extubated until after the consultant ward round the
following morning. Reducing extubation time to 405
minutes (<7 hours) allows most patients to be extu-
bated before consultant review, potentially accelerating
step-down decisions. This is supported by the multi-
variate analysis, in which protocol implementation had
a larger effect on patients admitted after hours (Ta-
ble 3). We do not know whether our observed reduc-
tion in ICU length of stay was associated with a
Ann Thorac Surg
2016;102:28–34
reduction in hospital stay, but a recent Cochrane re-
view concluded that fast-track protocols have no effect
on hospital length of stay [27].
Reduction in ICU length of stay may reduce cost. Our
ICU patients are charged a daily ICU fee of $825, although
additional ICU costs are incurred (eg, ventilation). The
median hospital cost for coronary artery bypass grafting
is $23,760 [34], and patients are counseled for an expected
bill of $24,750 before insurance and government sub-
sidies. Therefore, reducing ICU stay by 1 day potentially
saved at least 3% of the overall cost.
Limitations
As a retrospective, before and after observational study,
several limitations deserve consideration. First, both
groups were not identical. In particular, the preprotocol
group received more intraaortic balloon pumps and had a
lower median pH and higher median lactate on arrival to
the ICU. Although most clinicians would argue that the
statistically significant pH difference (7.37 versus 7.40) is
not clinically significant, the difference in lactate (3.56
versus 2.2 mmol/L) might be considered clinically rele-
vant. The lactate difference might be related to increased
intraaortic balloon pump use in the preprotocol group
because these patients had a higher lactate. However,
after adjusting for these differences (Table 3, Appendix B
Table 2), there was still a significant reduction in extu-
bation time.
A second limitation is the relatively small size of the
two groups. Larger groups could have been achieved with
a longer observational period, but this would increase the
chance of introducing bias from other practice changes.
During this short study period there were no other
changes to ICU or anesthesia management. Third, this
study design cannot exclude the potential for the Haw-
thorne effect to influence our findings.
Another potential limitation is unequal variance, as the
interquartile ranges are larger in the preprotocol group
(Table 2). Although this can be accounted for in the sta-
tistical analysis, we also argue that reduction of variance
is an important practice improvement goal, and has long
been recognized in industry as an important quality
marker [35].
Conclusions
In this study we have shown that introduction of a simple,
team-based extubation protocol for postoperative cardiac
surgery patients is associated with reduced extubation
time and reduced overall ICU length of stay without any
increase in extubation failure.
The authors wish to acknowledge Melvin J. Dajac, RRT-NPS,
Arman Del Rosario, RRT-NPS, Joseph Gammad, MD, and Smriti
Mahaju, MD, who helped with data collection, and Richard
Tierney, MD, who clarified hospital cardiac anesthesia guide-
lines. This work was supported in part by a grant from the Na-
tional Medical Research Council in Singapore (M.E.C.), NMRC/
TA/0015/2013, and Centre for Health Services and Policy
Research SBRO14/NS01G from the National University Health
Systems Pte Ltd (C.S.T.).
COVE ET AL 33
SIMPLE PROTOCOL REDUCES EXTUBATION TIME
ADULT CARDIAC
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