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J Thorac Cardiovasc Surg 1997;114:687-688
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Early tracheal extubation after coronary artery bypass grafting

Division of Cardiac Anesthesia
The Toronto Hospital
University of Toronto
585 University Dr.—BW 4-646
Toronto, Ontario M5G 2C4, Canada

Reply to the Editor:

I would like to thank Jucá and Monte for their interest and support of our prospective, randomized, controlled trial on morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass graft operations. ¹ As correctly indicated in their letter, the practice of early tracheal extubation in cardiac surgery is even more important in places with limited resources in this time of cost containment and environment. As a matter of fact, we ² have recently published a comprehensive cost study of early tracheal extubation in patients undergoing coronary bypass, including preoperative heart catheterization costs, physician fees, and all departmental costs from patient admission to discharge from the hospital. This study demonstrated that early tracheal extubation significantly reduces the cost of coronary artery bypass grafting by reducing the variable costs in the intensive care unit, reducing the length of stay in the intensive care unit, and reducing the postoperative hospital stay. This cost study further emphasizes that early extubation in these patients does not increase the postoperative morbidity or the cost of postoperative complications, as major postoperative complications were indeed very costly as documented. ² On the subject of resource use, early tracheal extubation resulted in fewer cancellations of cardiac operations by improving the use of the intensive care unit and allowed an increase in the caseload of cardiac surgery.

I congratulate Jucá and colleagues ³ on their earlier work and insight on early extubation in cardiac surgery. As indicated in our morbidity article, ¹ not only has the routine use of prolonged controlled ventilation in patients undergoing cardiac operations been standard practice for the past three decades, but early tracheal extubation in these patients is not new. Cost containment and efficient resource use force the pendulum back to the debate of early tracheal extubation in patients undergoing cardiac operations. As we indicated in our morbidity article, ¹ most of these earlier studies were observational studies, case reports, and retrospective reviews with minimal outcome measurements. The most common outcome measurements were mortality and reintubation rates. For example, Midell and coworkers, ⁴ in 1974, studied 100 cases of valve replacement surgery. This observational study measured morbidity with ventilator use and mortality. They appeared to have had a very high morbidity rate with a 10% tracheotomy rate and an 11% mortality rate. In such a study design, it is difficult to investigate the cause and effect that the delay in the use of the ventilator may have contributed to the death of some patients, because several patients who died were not given ventilatory support until a period of several hours to several days after completion of the operation. ⁴ As a result, morbidity and cost benefit issues of early versus late extubation in cardiac surgery continue to be debated, because the earlier studies had study design problems, small sample sizes, insufficient outcome measurements, and no control groups.

We therefore undertook this prospective, randomized, controlled clinical trial to evaluate the morbidity outcomes and safety of early tracheal extubation to late extubation in patients undergoing coronary artery bypass grafting. Our comprehensive outcome measurements included the following:

1. Cardiac morbidity outcome: myocardial ischemia, myocardial infarction, catecholamines stress response, and hemodynamic measurements
   
2. Ventilatory morbidity: apnea and respiratory patterns, arterial blood gases, alveolar-arterial gradient, and intrapulmonary shunting and oxygen consumption
   
3. Atelectasis, awareness, cognitive functions, and other major morbidity outcome and mortality. ¹
   

References

1. Cheng DCH, Karski J, Peniston C, et al. Morbidity outcome of early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 1996;112:755-64.[Abstract/Free Full Text]
   
2. Cheng DCH, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: a prospective, randomized, controlled trial. Anesthesiology 1996;85:1300-10.[Medline]
   
3. Jucá ER, Rolim JM, Monte L, et al. Extubação precoce após cirurgia cardiaca com C.E.C. Ref Col Brasileiro de Cirurgioes 1976;julho-agosto;163.
   
4. Midell AI, Skinner DB, De Buer A, Bermudez G. Review of pulmonary problems following valve replacement in 100 conservative patients: case against routine use of assisted ventilation. Ann Thorac Surg 1974;18:278.
   

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