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Early Tracheal Extubation for Adult Cardiac Surgical Patients

Hawkes, C A; Dhileepan, S; Foxcroft, D

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Background:

More than 30 studies have reported that early tracheal extubation (within 8 hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter intensive care unit and hospital stays.

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Objectives:

To assess the effects of early tracheal extubation and the impact of the extubating clinician’s profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for tracheal extubation within 4 hours or 4-8 hours.

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Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE (January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field.

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Selection criteria:

We selected randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair). Human investigation committee consent and written informed patient consent to do the studies was obtained.

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Data collection and analysis:

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted.

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Main results:

Six trials were included in the review. There was no evidence of a difference between early and conventionally tracheally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); 30 day mortality was 1.2 (0.63 to 2.27); myocardial ischemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (−7.42 to −6.61) and 1.08 days (−1.35 to −0.82), respectively).

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Reviewers’ conclusions:

There is no evidence of a difference in mortality and morbidity rates between the study groups. Early tracheal extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups.

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Suggested future areas of investigation:

establishing the safety and efficacy of immediate tracheal extubation compared with early tracheal extubation; establishing the most effective means of controlling pain and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients’ journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.

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Citation:

Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.

© 2004 International Anesthesia Research Society