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Is routine extubation overnight safe in cardiac surgery patients?

  • Krebs, Elizabeth D1
  • Hawkins, Robert B1
  • Mehaffey, J Hunter1
  • Fonner, Clifford E2
  • Speir, Alan M3
  • Quader, Mohammed A4
  • Rich, Jeffrey B5
  • Yarboro, Leora T1
  • Teman, Nicholas R1
  • Ailawadi, Gorav6
  • 1 Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
  • 2 Virginia Cardiac Services Quality Initiative, Virginia Beach, Va.
  • 3 INOVA Heart and Vascular Institute, Falls Church, Va.
  • 4 Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va.
  • 5 Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
  • 6 Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va. Electronic address: [email protected]
Published Article
The Journal of thoracic and cardiovascular surgery
Publication Date
Apr 01, 2019
DOI: 10.1016/j.jtcvs.2018.08.125
PMID: 30578055


Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database. Records from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00. A total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality. Extubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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