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J Thorac Cardiovasc Surg 1996;112:755-764
© 1996 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

MORBIDITY OUTCOME IN EARLY VERSUS CONVENTIONAL TRACHEAL EXTUBATION AFTER CORONARY ARTERY BYPASS GRAFTING: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Davy C. H. Cheng, MDa, Jacek Karski, MDa, Charles Peniston, MDb, Buvanendran Asokumar, MDa, Ganesh Raveendran, MDa, Jo Carroll, RNa, Hillary Nierenberg, RNa, Sandra Roger, RNa, Don Mickle, MDc, Jeff Tong, PhDc, J. Zelovitsky, MDd, Tirone David, MDb, Alan Sandler, MBa

Supported in part by a grant from the Anesthesia Patient Safety Foundation, American Society of Anesthesiologists, 1995, and by an Investigator Award from the Society of Cardiovascular Anesthesiologists granted to Dr. Cheng, 1995.

Presented in part at the Canadian Anaesthetists Society Annual Meeting, June 1994, and at the American Society of Anesthesiologists Annual Meeting, Oct. 1994.

Received for publication Jan. 4, 1996 Revisions requested Feb. 12, 1996; revisions received April 2, 1996; Accepted for publication April 3, 1996. Address for reprints: Davy Cheng, MD, The Toronto Hospital, BW 4-646, 585 University Ave., Toronto, Ontario, Canada M5G 2C4.

Abstract

Introduction: We undertook a prospective, randomized, controlled clinical trial to evaluate morbidity outcomes and safety of a modified anesthetic technique to provide shorter sedation and early extubation (1 to 6 hours) than those of the conventional anesthetic protocol used for prolonged sedation and extubation (12 to 22 hours) in patients after coronary artery bypass grafting. Methods: One hundred twenty patients undergoing elective coronary artery bypass grafting were prospectively assigned randomly to either an early extubation group (n= 60; 15µg·kg-1fentanyl and 2 to 6 mg ·kg-1·hour-1propofol and isoflurane) or to a conventional extubation group (n= 60; 50µg·kg-1fentanyl and 0.1 mg·kg-1midazolam and isoflurane). Cardiac morbidity (postoperative myocardial ischemia, postoperative myocardial infarction, and perioperative sympathoadrenal stress response), respiratory morbidity (postextubation apnea, alveolar-arterial oxygen gradient, pulmonary shunting, oxygen consumption, atelectasis, and reintubation), hemodynamic values and vasoactive medication requirements, intraoperative awareness, postoperative cognitive function, 30 day mortality, and intensive care unit and hospital lengths of stay were compared between the two groups. Results: Fifty-one of the 60 patients in each group (85%) were extubated within the defined time period. Postoperative extubation time and intensive care unit and hospital lengths of stay were significantly shorter in the early group. At 48 hours after operation, there were no significant differences between the two groups in myocardial ischemia incidences, ischemia burdens, or creatine kinase isoenzyme MB levels. Four patients in the conventional group, but not in the early group, had postoperative myocardial infarction. The extubation anesthetics used were effective in suppressing the perioperative plasma catecholamine stress response in both groups. Postextubation apnea characteristics were similar between the groups. Intrapulmonary shunt fraction improved significantly in the early group at 4 hours after extubation. The incidences and degree of atelectasis did not differ significantly between the two groups. The incidences of treated postoperative complications were comparable between the two groups, but three patients in the conventional group died as a result of stroke or postoperative myocardial infarction. Conclusion: Early extubation after coronary artery bypass grafting is safe and does not increase perioperative morbidity. There is an improvement in postextubation intrapulmonary shunt fraction and a reduction in intensive care unit and hospital lengths of stay. (J THORACCARDIOVASCSURG1996;112:755-64)




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