CARDIOTHORACIC ANESTHESIOLOGY:
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A Multidisciplinary Protocol-Driven
Approach to Improve Extubation Times
ADULT CARDIAC
After Cardiac Surgery
Joshua L. Chan, MD,* Justin G. Miller, MD,* Mandy Murphy, RN, Ann Greenberg, RN,
Margaret Iraola, RN, and Keith A. Horvath, MD
The National Institutes of Health Heart Center at Suburban Hospital, Bethesda, Maryland
Background. Prolonged intubation after cardiac sur-
gery is associated with significant morbidity. A fast-
track extubation protocol primarily driven by bedside
providers was instituted for all postoperative cardiac
surgery patients to facilitate safe and expeditious
extubation.
Methods. A retrospective review of 1,581 cardiac
surgery patients over an 8-year period was performed.
Before 2011, nonprotocolized standard perioperative
management was utilized (n [ 807). From 2011 onward,
a fast-track extubation (FTE) protocol directed by
bedside providers was instituted (n [ 774). Post-
operatively, patients were placed on pressure-regulated
volume control and titrated down to minimal support
to maintain peripheral capillary oxygen saturation
greater than 94%. For patients deemed ready for
weaning (no evidence of hypoxia, hemodynamic
instability, and so forth), a 30-minute continuous pos-
itive airway pressure trial was performed. Patients
meeting all neurologic, respiratory, and cardiovascular
criteria were extubated. The impact of the FTE
I mproving the management of cardiac surgery patients
supported on mechanical ventilation remains a signif-
icant area of focus to further optimize clinical outcomes.
The concept of fast-track extubation (FTE) for cardiac
surgery patients has become increasingly popular in an
effort to provide higher quality and more cost efficient
health care. Numerous studies have demonstrated that
early extubation within 6 to 8 hours can be safe while
reducing resource utilization and hospitalization costs [1–4].
Despite these benefits, the practice of timely extubation
remains inconsistent and emphasizes the need for a
protocolized approach to reducing variations and delays
Accepted for publication Feb 5, 2018.
*Drs Chan and Miller are co-first authors.
Presented at the Ninety-fifth Annual Meeting of the American Association
for Thoracic Surgery, Seattle, WA, April 25–29, 2015.
Address correspondence to Dr Horvath, 655 K St NW, No 100, Wash-
ington, DC 20001; email: khorvath@aamc.org.
Ó 2018 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
algorithm on timely extubation, clinical outcomes, and
safety was assessed.
Results. Baseline preoperative and intraoperative
characteristics were similar between pre-FTE and FTE
groups. Before instituting the FTE protocol, the rate of
early extubation (less than 6 hours) was 43.7%, and
increased to 64.1% during the FTE era (p < 0.001). Median
time to extubation was also found to be significantly
decreased: 295 minutes (interquartile range: 288) versus
385 minutes (interquartile range: 362, p ¼ 0.041). There
was no statistically significant difference in reintubation
rates or 30-day mortality.
Conclusions. The institution of a bedside provider-
directed FTE pathway reduced overall intubation times
and increased the rate of early extubation, without an
increase in reintubation or mortality. This program-wide
multidisciplinary approach appears to promote safe and
expeditious extubation of cardiac surgery patients.
(Ann Thorac Surg 2018;105:1684–90)
Ó 2018 by The Society of Thoracic Surgeons
in weaning ventilator support [5, 6]. Although the ad-
vantages of time-directed extubation protocols have been
well documented, the detailed characterization of explicit,
algorithmic rules directed toward early extubation that
are applicable to a diverse population of cardiac surgery
patients remains limited.
In the present study, we illustrate the implementation
of a standardized, multidisciplinary FTE protocol for all
adult patients undergoing cardiac surgery. Because the
efficacy of ventilator weaning practices is highly depen-
dent on provider involvement, the greater utilization of
staff resources may minimize interruptions in this pro-
cess. Accordingly, this protocol describes a stepwise
approach toward the successful discontinuation of me-
chanical ventilation support primarily driven by bedside
providers in contrast to conventional physician-directed
management. We sought to evaluate the impact of this
systemic pathway on cardiac surgery clinical outcomes,
hypothesizing that the use of this protocol can be safe and
efficacious in reducing the overall time to extubation.
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2018.02.008
Ann Thorac Surg
2018;105:1684–90
Patients and Methods
A retrospective review was performed of all adult cardiac
surgery patients (aged 18 years or more) from a single
institution. Case types included coronary artery bypass
graft surgery, valve repair or replacement, aortic aneu-
rysm repair, or a combination of these, and surgery was
performed in an elective, urgent, or emergent setting.
Institutional Review Board study approval was obtained
with waiver for the need for consent. This 8-year study
period included respiratory management practices before
and during the use of a formalized FTE algorithm. Pre-
viously, ventilator support weaning and extubation was
initiated and closely managed by the intensive care unit
attending physician. After the institution of the FTE pro-
tocol, respiratory therapy and nursing staff primarily
directed this process, with the decision to extubate per-
formed independently of the intensivist when specific
criteria were achieved.
This FTE protocol, as shown in Figure 1, was formulated
after a literature review of fast-track and early extubation
protocols in cardiac surgery. The FTE protocol was ulti-
mately conceived based on a multidisciplinary discussion
between cardiac surgeons, cardiac intensive care unit
attending physicians, nursing staff, and respiratory thera-
pists. The protocol was designed with several checkpoints
integrated to ensure safe and prudent extubation. If the
criterion for one of these steps was not met, that step was
repeated until it was completed. An advanced airway cart
was readily accessible on the unit, although patients with
known difficult airway were not contraindicated to un-
dergo FTE. All staff working in the cardiac intensive care
unit were required to undergo orientation of the protocol,
and compliance was ensured with oversight provided by
the division head of cardiac surgery.
Although an intensive care unit attending physician
was continually available, the progression through the
majority of checkpoints was implemented by nursing and
respiratory therapy staff. On arrival to the intensive care
unit, mechanical ventilation was initially set to the
following settings: pressure-regulated volume control
mode, tidal volume 10 mL/kg, respiratory rate 14 to 16
breaths per minutes, positive end-expiratory pressure 5
cmH2O, and fraction of inspired oxygen 100%. Adjust-
ments were performed based on arterial blood gas mea-
surements to achieve adequate oxygenation and
ventilation (pH 7.35 to 7.45, pCO2 35 to 45 mm Hg, PaO2
greater than 90 mm Hg, peripheral oxygen saturation
greater than 94%); fraction of inspired oxygen was addi-
tionally weaned to 40% to maintain peripheral capillary
oxygen saturation greater than 94%. When the patient
was deemed ready for weaning (awake, hemodynami-
cally stable, minimal ventilator support), a spontaneous
breathing continuous positive airway pressure trial was
performed. Patients tolerating continuous positive airway
pressure for 20 to 30 minutes without tachypnea, hypoxia,
or hemodynamic instability were extubated by the res-
piratory therapist.
A retrospective review was conducted comparing out-
comes between patients treated with the FTE protocol
CHAN ET AL 1685
EXTUBATION PROTOCOL IN CARDIAC SURGERY
and patients not treated with the FTE protocol. The pri-
mary endpoint was the time to extubation, which was
defined as the interval from the conclusion of the index
surgical operation until the removal of the endotracheal
tube. Secondary endpoints evaluated additional post-
ADULT CARDIAC
operative outcomes, including rate of reintubation, need
for reoperative intervention or intensive care unit (ICU)
readmission, ICU length of stay, postoperative hospital
length of stay, inhospital mortality, and 30-day survival.
Continuous variables were presented as a median with
interquartile range (IQR) and categoric variables were
reported as percentages. Statistical comparisons between
the pre-FTE and FTE groups with respect to baseline
characteristics and outcomes were made using the
Wilcoxon two-sample test for continuous variables and
Fisher’s exact two-tailed test for categoric variables. All
analyses were performed using SAS software (version 9.2;
SAS Institute, Cary, NC) or R software (version 3.0.2;
R Foundation for Statistical Computing, Vienna, Austria).
Results
During the 8-year study period, 1,581 consecutive patients
underwent cardiac surgery, with the FTE protocol imple-
mented in July 2011. Before implementing the FTE proto-
col, 807 patients were managed with conventional
practices standard to our institution; 774 patients were
treated while the FTE protocol was operational. Baseline
demographics were similar between pre-FTE and FTE-
treated patients, with a median age of 68 years and a
body mass index of 27.0 kg/m2 in both groups (Table 1). The
presence of several medical comorbidities, cardiac-related
risk factors, and prior cardiac surgery was also not signif-
icantly different, except for a decrease in moderate chronic
lung disease (18.8% versus 13.9%, p ¼ 0.010) and an in-
crease in tobacco use (26.8% versus 13.5%, p ¼ 0.005) in the
FTE group. Table 2 displays intraoperative characteristics
of the study population. No statistically significant differ-
ence in the case status urgency was noted, with comparable
cardiopulmonary bypass, aortic cross-clamp, and total
procedure times observed between cohorts. None of the
patients in this study required circulatory arrest. There was
also no statistically significant difference in the pre-FTE
and post-FTE rates of coronary artery bypass graft sur-
gery, valve repair or replacement, aortic aneurysm repair,
or a combination of those procedures.
On examination of postoperative endpoints (Table 3),
the implementation of the FTE protocol was associated
with a significant decrease in median intubation times:
295 minutes (IQR: 288) versus 385 minutes (IQR: 362,
p ¼ 0.041). In addition to reducing overall time on me-
chanical ventilation, the percentage of extubation occurring
within 6 hours was significantly greater in FTE-treated
patients (64.1% versus 43.7%, p < 0.001). Despite
increasing the frequency of early extubation, the rate of
reintubation was not found to be increased (7.8% versus
7.2%, p ¼ 0.702) and did not negatively affect inhospital
mortality (2.6% versus 2.6%, p ¼ 1.000) or 30-day survival
(96.5% versus 96.8%, p ¼ 0.782). The rate of prolonged
intubation (longer than 24 hours) was also significantly
 1686 CHAN ET AL Ann Thorac Surg
EXTUBATION PROTOCOL IN CARDIAC SURGERY 2018;105:1684–90
ADULT CARDIAC

Fig 1. Fast-track extubation protocol instituted for all cardiac surgery patients. (ABG ¼ arterial blood gas; CPAP ¼ continuous positive
airway pressure; CTU ¼ Cardiothoracic Unit; FiO2 ¼ fraction of inspired oxygen; PaO2 ¼ partial pressure of oxygen content in arterial blood;
pCO2 ¼ partial pressure of carbon dioxide in arterial blood; PEEP ¼ positive end-expiratory pressure; PS ¼ pressure support; RN ¼ registered
nurse; RT ¼ respiratory therapist; SpO2 ¼ peripheral capillary oxygen saturation.)
Ann Thorac Surg CHAN ET AL 1687
2018;105:1684–90 EXTUBATION PROTOCOL IN CARDIAC SURGERY

Table 1. Patient Demographics Table 2. Intraoperative Characteristics

Pre-FTE FTE p Pre-FTE FTE p
Demographics (n ¼ 807) (n ¼ 774) Value Characteristics (n ¼ 807) (n ¼ 774) Value

Age, years 68 (18) 68 (17) 0.330 Status

ADULT CARDIAC
Male 69.4 (560/807) 72.1 (558/774) 0.224 Elective 49.9 (403/807) 46.8 (362/774) 0.209
White 73.1 (590/807) 71.1 (550/774) 0.370 Urgent 45.7 (369/807) 47.7 (369/774) 0.450
Body mass index, kg/m2 27.0 (5.9) 27.0 (7.2) 0.151 Emergent 4.3 (35/807) 5.6 (43/774) 0.296
Medical comorbidities Case type
Cerebrovascular 5.0 (40/807) 4.3 (33/774) 0.550 CABG 59.6 (481/807) 56.6 (438/774) 0.241
accident Valve 30.0 (242/807) 31.0 (240/774) 0.662
Diabetes mellitus 27.0 (218/807) 28.4 (220/774) 0.537 CABG plus valve 9.4 (76/807) 10.6 (82/774) 0.451
Hypertension 81.4 (657/807) 78.3 (606/774) 0.132 Othera 0.1 (8/807) 0.2 (14/774) 0.120
Hyperlipidemia 79.9 (645/807) 82.3 (637/774) 0.248 CPB time, minutes 116 (47) 116 (54) 0.802
Hemodialysis 1.73 (14/807) 1.6 (12/774) 0.844 Aortic cross-clamp time, 88 (36) 86 (43) 0.493
Tobacco use 13.5 (109/807) 26.8 (152/807) 0.005 minutes
Chronic lung disease 18.8 (152/807) 13.9 (108/774) 0.010 Total procedure time, 232 (106) 229 (108) 0.300
Mild 11.6 (94/807) 10.1 (78/774) 0.332 minutes
Moderate 5.0 (40/807) 2.5 (19/774) 0.011 a
Includes aortic aneurysm repair with or without valve replacement.
Severe 2.2 (18/807) 1.8 (13/774) 0.472
Values are median (interquartile range) or percentage (n/N).
Cardiac medical and surgical history
Prior myocardial 30.5 (246/807) 30.7 (238/774) 0.913 CABG ¼ coronary artery bypass graft surgery; CPB ¼ cardiopulmo-
nary bypass; FTE ¼ fast-track extubation.
infarction
Prior cardiac 20.9 (169/807) 22.1 (171/774) 0.582
intervention
Prior CABG 2.9 (23/807) 3.9 (30/774) 0.267 FTE eras to further assess the impact of the extubation
Prior valve surgery 1.7 (14/807) 2.5 (19/774) 0.380 algorithm (Table 5). In contrast to the earlier evaluation of
the entire study population demonstrating similar de-
Values are median (interquartile range) or percentage (n/N). mographics between conventional and FTE-managed
CABG ¼ coronary artery bypass graft surgery; FTE ¼ fast-track patients (irrespective of total intubation times), a number
extubation. of unique distinctions were observed in a subset analysis
of patients who were not extubated early. Although sex
reduced after FTE implementation (4.9% versus 7.3%, and age were similar, the percentage of nonwhite race
p ¼ 0.046), although there did not appear to be a dif- and emergent case status was greater in this subgroup of
ference in the specific subset of patients with intubation FTE-treated patients. The prevalence of diabetes mellitus,
longer than 72 hours (2.1% versus 2.5%, p ¼ 0.615). hemodialysis, and prior myocardial infarction, as well as
Discrete evaluation of patients during the FTE era was total procedure time, rate of reintubation, and ICU length
subsequently performed to assess risk factors associated of stay trended higher in the FTE group compared with
with early versus non–early extubation while the protocol
was in place, as shown in Table 4. Patients who were
extubated later were demographically noted to be older Table 3. Postoperative Outcomes
(71 years [IQR: 16] versus 66 years [IQR: 16], p < 0.001)
with reduced proportions of male and whites. Non–early Pre-FTE FTE
extubation patients were noted to have a higher preva- Outcomes (n ¼ 807) (n ¼ 774) p Value
lence of hemodialysis (2.9% versus 0.8%, p ¼ 0.034) and a Time to extubation, 385 (362) 295 (288) 0.041
history of prior myocardial infarction (37.8% versus minutes
26.8%, p ¼ 0.002) compared with their early extubation Intubation <6 hours 43.7 (353/807) 64.1 (496/774) <0.001
peers. They also represented a significantly greater pro- Intubation >24 hours 7.3 (59/807) 4.9 (38/774) 0.046
portion of emergent case statuses (11.2% versus 2.4%, Intubation >72 hours 2.5 (20/807) 2.1 (16/774) 0.615
p < 0.001) and had longer median procedure time (245 Reintubation 7.2 (58/807) 7.8 (60/774) 0.702
minutes [IQR: 101] versus 221 minutes [IQR: 109], p ¼ 0.039). Reoperation for bleeding 6.4 (52/807) 4.9 (38/774) 0.097
Extubation during earlier timeframes was not associated ICU readmission 2.4 (19/807) 3.0 (23/774) 0.532
with statistically significant changes in morbidity (rein- ICU LOS, hours 22 (19) 21 (9) 0.413
tubation, ICU readmissions, length of stay), and inhos- Postoperative LOS, days 4 (2) 4 (3) 0.317
pital mortality (3.1% versus 2.3%, p ¼ 0.641) and 30-day Inhospital mortality 2.6 (21/807) 2.6 (20/774) 1.000
survival (96.3% versus 96.4%, p ¼ 1.000) remained
Thirty-day survival 96.8 (781/807) 96.5 (747/774) 0.782
similar compared with the group who were not extubated
early. Values are median (interquartile range) or percentage (n/N).
Analysis was additionally carried out on patients who FTE ¼ fast-track extubation; ICU ¼ intensive care unit; LOS ¼
were not extubated within 6 hours in both pre-FTE and length of stay.
 1688 CHAN ET AL Ann Thorac Surg
EXTUBATION PROTOCOL IN CARDIAC SURGERY 2018;105:1684–90

Table 4. Comparison of Fast-Track Extubation–Treated Table 5. Time to Extubation More Than 6 Hours, Stratified by
Patients, Early Extubation (6 Hours) Versus No Early Extubation Methodology
Extubation (>6 Hours)
Pre-FTE FTE p
Early No Early Variables (n ¼ 454) (n ¼ 278) Value
Extubation Extubation p
ADULT CARDIAC

Variables (n ¼ 496) (n ¼ 278) Value Age, years 72 (18) 71 (16) 0.259

Male 67.6 (307/454) 64.0 (178/278) 0.334
Age, years 66 (16) 71 (16) <0.001 White 71.8 (326/454) 62.9 (175/278) 0.017
Male 76.6 (380/496) 64.0 (178/278) <0.001
Diabetes mellitus 27.3 (124/454) 30.6 (85/278) 0.355
White 75.6 (375/496) 62.9 (175/278) <0.001
Hemodialysis 2.2 (10/454) 2.9 (8/278) 0.626
Hemodialysis 0.8 (4/496) 2.9 (8/278) 0.034
Prior myocardial infarction 31.7 (144/454) 37.8 (105/278) 0.108
Prior myocardial 26.8 (133/496) 37.8 (105/278) 0.002 Status
infarction
Elective 43.4 (197/454) 35.6 (99/278) 0.044
Status
Urgent 46.5 (211/454) 53.2 (148/278) 0.080
Elective 53.0 (263/496) 35.6 (99/278) <0.001
Emergent 6.6 (30/454) 11.2 (31/278) 0.038
Urgent 44.6 (221/496) 53.2 (148/278) 0.024
CPB time, minutes 119 (46) 130 (62) 0.025
Emergent 2.4 (12/496) 11.2 (31/278) <0.001
Aortic cross-clamp time, 89 (36) 92 (48) 0.197
CPB time, minutes 109 (49) 130 (62) <0.001 minutes
Aortic cross-clamp time, 83 (39) 92 (48) <0.001 Total procedure time, 237 (105) 245 (101) 0.102
minutes
minutes
Total procedure time, 221 (109) 245 (101) 0.039
Time to extubation, minutes 1160 (607) 1335 (635) 0.358
minutes
Reintubation 6.8 (31/454) 8.3 (23/278) 0.470
Reintubation 7.5 (37/496) 8.3 (23/278) 0.677
Reoperation for bleeding 5.5 (25/454) 3.2 (9/278) 0.205
Reoperation for bleeding 5.8 (29/496) 3.2 (9/278) 0.120
ICU readmission 2.2 (10/454) 4.3 (12/278) 0.120
ICU readmission 2.2 (11/496) 4.3 (12/278) 0.122
ICU LOS, hours 58 (28) 67 (46) 0.282
ICU LOS, hours 21 (4) 67 (46) <0.001
Postoperative LOS, days 5 (2) 5 (3) 0.950
Postoperative LOS, days 4 (3) 5 (3) 0.141
Inhospital mortality 2.4 (11/454) 2.2 (6/278) 1.000
Inhospital mortality 2.8 (14/496) 2.2 (6/278) 0.645
Thirty-day survival 96.7 (439/454) 96.4 (268/278) 0.836
Thirty-day survival 96.6 (479/496) 96.4 (268/278) 1.000
Values are median (interquartile range) or percentage (n/N).
Values are median (interquartile range) or percentage (n/N).
CPB ¼ cardiopulmonary bypass; FTE ¼ fast-track extubation;
CPB ¼ cardiopulmonary bypass; ICU ¼ intensive care unit; ICU ¼ intensive care unit; LOS ¼ length of stay.
LOS ¼ length of stay.

pre-FTE but was not statistically significant. However,
postoperative hospital length of stay, inhospital mortality,
and 30-day survival remained similar with FTE in this
high-risk cohort.
Comment
The present study examined the impact of a formalized,
program-wide fast-track multidisciplinary extubation
protocol, and makes several unique observations.
Compared with historic controls who were managed with
conventional weaning techniques, the bedside provider-
driven FTE protocol was effective in reducing overall
time to extubation by 20%. Metrics of safety, specifically
the rate of reintubation, frequency of ICU readmission,
and immediate postoperative mortality, were also found
to be similar between treatment groups. This suggests
that an FTE algorithm primarily directed by nursing and
respiratory therapy staff specifically in the context of
postoperative cardiac surgery can be safely implemented.
This paradigm shift may have significant implications in a
high-acuity cardiac surgery ICU environment with
limited physician resources. Although the importance of
appropriate physician supervision cannot be understated,
frequent disruptions requiring close attention and man-
agement by the surgeon or intensivist of the critically ill
may inadvertently delay the ventilator weaning process of
separate, stable postoperative cardiac surgery patients.
The use of this FTE protocol allows for the inclusion of
additional, appropriately skilled health care providers,
thereby optimizing staff utilization and minimizing in-
terruptions to the ventilator liberation process.
Several initiatives, including The Society of Thoracic
Surgeon’s National Database and the National Quality
Forum’s National Voluntary Consensus Standards,
identify tracheal intubation duration as an important
quality control measure [7, 8]. Standardized weaning
protocols have been cited as an important component in
this ongoing effort to optimize mechanical ventilation
practices [5, 9–11]. The primary benefit of implementing
a protocol is the ability to lessen inconsistencies and
variability in the management of complex patients, and
has frequently been used to achieve quality care im-
provements in the ICU setting [12, 13]. Previous reports
have described the clinical and economic benefits of an
extubation protocol in specific cardiac surgery pop-
ulations, such as after coronary artery bypass graft sur-
gery or elective circumstances [1, 3, 6, 14–18]. The FTE
algorithm used in this study was successfully applied to
a diverse range of cardiac surgery operations and risk
groups, including both elective and nonelective cases. As
others have also discussed, protocols requiring multiple
Ann Thorac Surg
2018;105:1684–90
complex steps or interventions, such as arterial blood
gasses after each ventilator setting change, can impede
the process of FTE [19, 20]. We found that the overall
simplicity of this pathway by minimizing the number of
steps required and the general dependence on objective
criteria to be advantageous in increasing the frequency
of successful early extubation without diminishing pa-
tient safety. We also observed an overall decrease in the
rate of prolonged intubation (more than 24 hours), which
has been previously highlighted as an important per-
formance benchmark and a risk factor for operative
mortality [7, 8, 16]. For patients requiring mechanical
ventilation support for 3 days or more, FTE did not
appear to have a significant effect, arguing that further
work is required in optimizing respiratory outcomes in
this subpopulation.
Previous FTE pathways have described heterogenous
effects on ICU and hospital lengths of stay [9, 16, 21–24].
In the present study, no significant difference in ICU or
postoperative length of stay was observed. However, that
may not be unexpected considering the relatively short
critical care requirements in historic controls as median
ICU length of stay before instituting the FTE protocol was
22 hours and further, statistically significant reduction
may have been challenging.
Separate consideration of FTE era patient baseline and
perioperative variables was performed to determine
characteristics of early versus non–early extubation. Most
investigators describe early extubation as between 4 and 8
hours, and in this study, it was defined as extubation within
6 hours [25]. This examination revealed that age, sex, renal
disease, case status, and total procedure time were risk
factors. Similar to prior reports, we observed that sicker
patients with more comorbidities were associated with
extubation times greater than 6 hours [6, 19, 26]. We sur-
mise that the FTE protocol inherently identified healthier
patients (eg, minimal risk factors, shorter intraoperative
time requirements) who were generally expected to be
successful early extubation candidates, thereby systemat-
ically encouraging timely respiratory weaning of appro-
priate patients. That is further emphasized when
comparing non–early extubation cases in the pre-FTE and
FTE periods. In contrast to pre-FTE, this FTE-treated sub-
group (extubation more than 6 hours) appears to primarily
consist of patients with an increase in comorbid factors.
The safety of the FTE protocol is further delineated in the
FTE-treated subgroup (extubation more than 6 hours), as
this subgroup potentially reflects the remaining sicker
patients who legitimately require additional ventilator
support time, whereas the healthier cohort was extubated
earlier. Despite this, morbidity, inhospital mortality, and
30-day survival were similar.
Several limitations of this study are recognized.
Although patient demographics from pre-FTE and FTE
treatment periods were statistically similar, inherent
weaknesses related to a single-institution retrospective
review are appreciated. We were also unable to exclude
variations in perioperative sedation, although conven-
tional cardiac anesthetic techniques were utilized
CHAN ET AL 1689
EXTUBATION PROTOCOL IN CARDIAC SURGERY
throughout the study period. Furthermore, this study did
not assess other aspects that would be considered part of
fast-track cardiac care, such as low-dose opioid admin-
istration or the use of early discharge criteria. The indi-
vidual assessment of this extubation algorithm was
ADULT CARDIAC
chosen to assess its discrete impact on mechanical
ventilation requirements and to minimize the potential
confounding effects of multiple interventions. However,
future incorporation of this FTE protocol within a
comprehensive fast-track pathway may be beneficial.
Moreover, the influence of other risk factors on successful
early extubation with FTE remains unknown; further
research on particular conditions, such as baseline CO2
retainers, will be necessary and certainly helpful in opti-
mizing outcomes. Prolonged intubation has been known
to contribute to ICU delirium, and specific appraisal of
this fast-track protocol on improving cognitive outcomes
will be of interest. Although the economic impact of this
protocol was not directly assessed, we hypothesize that
there was a cost-neutral or cost-negative effect secondary
to the reduction in ventilator equipment, laboratory
draws, and support required.
We conclude that the use of a formalized FTE protocol
primarily driven by bedside providers was associated with
a significant reduction in mechanical ventilation times
after cardiac surgery. In addition, this systemic approach
was effective in increasing the frequency of early extubation
within 6 hours postoperatively. These results encourage
further evaluation of this multidisciplinary protocol for safe
and expeditious postoperative recovery within the context
of fast-track cardiac surgery care.
The authors acknowledge the contributions of the critical care
nursing and respiratory therapy staff: Melissa Means, MD,
Angela Toro, RN, Periwinkle MacKay, RN, Linda Krause, ACNP,
Melanie Sparks, ACNP, Mary Evans, ACNP, Sarah Rasmussen,
RN, and Carl Voss, RRT. None of the authors has any conflicts of
interest or relevant financial relationships with an external or
commercial entity to disclose. No external funding sources were
provided for this study. No external or commercial entities were
involved in this study’s design, collection, analysis, or interpre-
tation of data. The authors had access to all the data in this study
and take complete responsibility for the integrity of the study
design, data, and accuracy of the data analysis. The decision to
write this report and to submit it for publication was made
independently by the authors.
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EXTUBATION PROTOCOL IN CARDIAC SURGERY
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