1. Early Extubation and Accelerated Recovery Protocols in Cardiac Surgery
Glenn Whitman M.D.
Symposium for Allied Health Personnel
AATS Annual Meeting 2015
Seattle, Washington
September 18, 2018

2. Early Extubation and Accelerated Recovery Protocols in Cardiac Surgery
Disclosures: None
September 18, 2018

3. Post-Op SSI and PNA Rate in Open Heart Surgery Patients
Johns Hopkins Hospital: 11/2011 – 3/2014 (n = 2253)

4. Mean Prolonged Ventilation Rate after Isolated CABG (2011-2013)
SD= 6%
(N = 356,000)
SD= 4%
SD= 3%

5. Background: Early Extubation

6. Background: Early Extubation
Early Extubation Predicts Improved Outcomes
N= Isolated CABG, Isolated valve, CABG+valve
42% extubated < 6 hours
Propensity analysis showed the associated benefits of early extubation
Source: Stamou SC, Camp SL, Stiegel RM et al. JTCVS 2008;136:4
Lobdell, Sanger Heart Institute, Charlotte, NC

7. Benefits of Early Extubation
Complications in Early Extubation Group vs. Propensity Matched Group
(n= 980 vs. propensity matched group)
Odds Ratio*
95% Confidence Interval
P-value
Renal Failure
0.22
<0.001
Any Infectious Complication
0.46
Pneumonia
0.35
Prolonged LOS ICU (24 hrs)
0.42
Prolonged Hospital LOS (>9 days)
0.37
Operative Mortality
0.44
0.006
*In favor of early extubation
Source: Camp SL, Stamou SC, Stiegel RM, et al, J Card Surg 2009;24:

8. Background: >30 studies reported that extubations
Early Extubation For Adult Cardiac Surgery Patients: Cochrane Database Systematic Review 2012
Hawkes CA, Khileepan S, Foxcroft D
Background: >30 studies reported that extubations
in < 8 hours appear to be safe, with possible savings in cost due to LOS
This review: 6 trials with 871 patients in the intervention or control groups, mostly CABG

9. Early Extubation: Why It Matters

10. Keys to Performance Improvement
Leader – Clinical and knowledgeable re: QA/PI
Physician?
Infrastructure
Human resources: data analysis, familiarity with healthcare
Access to data
STS support
Scheduled meetings
Frequent
All disciplines including administration
Data presentation
Targets and current performance

11. The CSICU Dashboard The Sine Qua Non of Performance Improvement
CT Cases Admitted to CSICU by Month
6 hour and Prolonged Vent Times
Hospital LOS (CABG, Valve, Aortic Root Replacement)
Blood Exposure
CSICU LOS (CABG, Valve, Aortic Root Replacement)
CVL Infections
Cardiac Surgery LOS v. University Health Consortium Expected LOS
VAP Infections
Drug Utilization and Cost (Albumin, Diuril, and Nicardipine)
Checklist Compliance
CABG SCIP Measure Compliance
Transfer Data
Other Cardiac SCIP Measure Compliance
Hand Washing Compliance
SCIP Blood Glucose
iNO Utilization
Beta-blocker Administration Preop

12. Early Extubation Performance at the Johns Hopkins Hospital

13. Hypothesis Two changes could improve early extubation performance
Creating and adopting an agreed upon standard extubation protocol
Charging the nurse and respiratory therapist (RT), not the physician or mid-level provider, with its implementation

14. New MV Weaning Protocol
Beginning October 1, 2009
RR 16
TV 6-8 cc per kg ideal body weight
Paralytic reversal at 36°C
Nurse then empowered to determine extubation timing: hemodynamic stability, no/minimal bleeding, resolution of acidosis, ability to communicate
Nurse then called RT to do “minimals”. PSV 5cmH20 CPAP 5cmH2O. ABG after 30 minutes w/testing of respiratory mechanics. Blood gas returned and only then was the provider called.

15. Pre vs. Post Implementation of New MV Weaning Protocol
* p<0.01 compared to JHH Period 1

16. Continuous Performance Evaluation
Multidisciplinary Committee
Continued to monitor and noticed room for improvement
Hypothesis:
Further improvement in early extubation rates would occur with the addition of:
Earlier reversal of paralysis at 35.5°C rather than 36°C
Placement of a highly visible pink reminder sheet in every patient room upon ICU admission

17. A bow around your finger!

18. Results Following Additional Protocol Changes
% Patients Extubated
<6hrs
(CABG Only)
n= 236
JHH Period JHH Period JHH Period 3
(1/3/2005-9/29/2009) (10/1/2009-8/31/2011) (9/1/2011-6/30/2012)
* p<0.01 compared to JHH Period 1
Ŧ p<0.01 compared to JHH Period 2

19. Extubation < 6 Hours Current Performance: 2014
STS Like Institutions 2014
% Patients Extubated
<6hrs
(CABG Only)
n= 348
n= 236 Ŧ
n= 637 *
n= 1174

22. 0%

23. Extubation Best Practices
Target an extubation time of 5 hours
Start the process at 35° C
Indications for spontaneous breathing trial:
Resolution of ongoing acidosis
Chest tube drainage of <200 mL/hour for 2 hours (<150 mL/hour may be too stringent)
Extubation initiated/ overseen by RT/RN, not MD/Provider
MCSQI Tenets of an “Early Extubation Protocol” Spring 2015

25. Start by addressing base deficit: acidosis decreases myocardial contractility, increases its irritability, decreases the effect of catechols, and raises pulm vasc resistance. So we treat it.
Then address the x axis, and the range of K concentrations. Hypokalemia hyperpolarizes the cell membrane which in fact makes it irritable (Na channel effect). So we treat it.
But giving bicarb to a hypokalemic patient exacerbates the hypokalemia. So in this left lower quadrant, we are stuck, as we have to wait to give K (which cannot be pushed) in order to treat the base deficit. And on top of that, if the patient is hyperglycemic, we cannot give insulin as this exacerbates the problem even further.
Base Deficit

26. Potassium
The entire process of extubation and BG management waits for the repletion of K
Base Deficit

28. Patient care is not an individual sport, but rather, it is a Team Game
Conclusions
Early Extubation is a surrogate for a systems approach to care
Hypothermia, Hypokalemia, Base Deficits prolong the process
Early Recovery starts in the OR
Improvement requires measurement and review, over and over
Surgeons, Anesthesiologists, RT, RN, and YOU are involved
Patient care is not an individual sport, but rather, it is a Team Game
September 18, 2018