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Immediate or Early Extubation: Where Do We Start?

Royse, Colin MBBS, MD, FANZCA; Soeding, Paul MBBS, BSc, FANZCA; Royse, Alistair MBBS, MD, FRACS

doi: 10.1097/00000539-200104000-00053
Letters To The Editor: Letters & Announcements

Department of Anesthesia and Pain Management, The Royal Melbourne Hospital, and Department of Pharmacology, The Unviersity of Melbourne

Department of Cardiac Surgery, The Royal Melbourne Hospital, and Department of Surgery, The University of Melbourne

To the Editor:

We commend Montes and colleagues (1) for their study investigating immediate extubation after coronary artery bypass surgery. We are not entirely surprised that they had a more frequent than expected reintubation rate. The key to successful immediate or very early extubation is to have the patient normothermic, hemodynamically stable, awake, and to provide adequate nonopioid analgesia (2). Two aspects of their technique may have contributed to reintubation. The mean minimum temperature in both groups was below 32°C, which could lead to early hypothermia despite “full rewarming” during cardiopulmonary bypass. They do not mention whether forced air warmers were used to maintain normothermia after the termination of cardiopulmonary bypass. Hypothermia could lead to restlessness and shivering. Secondly, they used opioid-based analgesia, which could contribute to respiratory depression. We agree that cost savings are unlikely with immediate versus very early extubation unless there is an additional staff requirement to provide ventilatory support. Although we have performed immediate extubation without reintubation, it is a technique that demands exact fulfilment of the conditions mentioned above, and is made simpler by the use of epidural anesthesia. Commencing spontaneous ventilation in the operating theater and performing tracheal extubation in the intensive care unit can achieve most goals of immediate extubation. This is a simpler and perhaps safer approach for surgical units aiming for very early extubation.

Colin Royse, MBBS, MD, FANZCA

Paul Soeding, MBBS, BSc, FANZCA

Alistair Royse, MBBS, MD, FRACS

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1. Montes FR, Sanchez SI, Giraldo JC, et al. The lack of benefit of tracheal extubation in the operating room after coronary artery bypass surgery. Anesth Analg 2000; 91: 776–80.
2. Royse C, Royse A, Soeding P. Routine immediate extubation after cardiac operation: a review of our first 100 patients. Ann Thorac Surg 1999; 68: 1326–9.
© 2001 International Anesthesia Research Society