Volume 17, Issue 1 , Pages 36-39, February 2003
Early extubation after single-lung transplantation: Analysis of the first 106 cases☆
Article Outline
Abstract
Objective: To determine if a modern anesthetic approach permits extubation immediately after surgery for single-lung transplantation. Design: A retrospective study of all patients undergoing single-lung transplantation from June 1993 to December 1999 in Denmark. Setting: Rigshospitalet, Copenhagen University hospital. Participants: One hundred six consecutive patients scheduled for single-lung transplantation. Interventions: From July 1997, the anesthetic approach was changed to facilitate early extubation. The changes included epidural analgesia and short-acting anesthetic drugs. Measurements and Main Results: One hundred six patients were anesthetized for single-lung transplantation. The first 33 patients were moved to the intensive care unit for postoperative mechanical ventilation. After the change of anesthesia technique, 53 of 73 patients were extubated in the operating room. Eleven patients needed reintubation within the first 24 hours because of respiratory insufficiency, pulmonary edema, hemorrhage, or pneumothorax. The need for reintubation increased the length of stay in the intensive care unit by 1 day from 2 to 3 days (NS). The possibility of early extubation or the need for reintubation was not related to age, weight, sex, preoperative condition, mode of transport of the graft, duration of graft ischemia, or side of transplantation. Conclusion: This study has shown that it is possible to extubate patients in the operating room immediately after single-lung transplantation in the majority of cases. Copyright 2003, Elsevier Science (USA). All rights reserved.
Keywords: Lung transplantation, anesthesia, extubation
Lung transplantations started in Denmark in 1990 after the introduction of brain death criteria. Transplantations of either one or both lungs have been performed since then. Initially, anesthesia for all lung transplantations was planned with a period of postoperative mechanical ventilation in the intensive care unit (ICU); but with changes in anesthetic approach and the experience of very stable patients after replacement of one lung, extubation in the operating room (OR) was considered.
Haydock et al1 reported weaning from ventilation a few hours postoperatively, but it was unusual to extubate within 12 hours. In other reports, extubation 10 to 18 hours postoperatively2 is considered as early extubation, and even a mean extubation time of 2.3 days3 is mentioned.
Lee et al4 showed a median length of ventilation (LOV) of 2 days. The tendency seems to be early weaning from ventilation in the ICU,5, 6 eventually followed by continuous positive airway pressure by face mask in which median LOV was 3.5 hours and the range was 1 to 312 hours.7
Two reasons in favor of early extubation can be stated: (1) it is economical because LOV is correlated to the length of stay in the ICU, and it may decrease costs, although it has not been proven for lung transplantations or other major surgery,8 and (2) it decreases the complications associated with mechanical ventilation such as hemodynamic instability, pulmonary colonization of gastrointestinal micro-organisms, sepsis, risks of barotrauma, and bronchial anastomosis leak because the need for sedatives or opioids inhibits gastrointestinal motility.9, 10 On the contrary, the therapy of postoperative graft failure will often include mechanical ventilation.
The anesthetic approach to early extubation of single-lung transplantation (SLTX) patients in OR includes short-acting drugs,11 normothermia at extubation, and effective analgesia postoperatively with a minimum of sedation and respiratory depression has not previously been reported. The authors have performed 106 SLTX from June 1993 to December 1999. This report is a retrospective survey of all cases using medical records.
The authors hypothesize that, with a modern anesthetic approach, it will be possible to extubate patients undergoing SLTX successfully in the OR in a majority of cases. Furthermore, the possibility of influence from other factors such as sex, age, side of transplantation, duration of graft ischemia, mode of transportation of graft, and preoperative forced expiratory volume in 1 second (FEV1) is considered.
Methods
Data from all SLTX recipients at Rigshospitalet, Copenhagen University Hospital from June 1993 until December 1999 were extracted from medical records, including sex, age, weight, side of transplantation, mode of transportation of graft (eg, airplane/barotraumas), and duration of ischemia were correlated to successful extubation in OR, frequency of reintubation within 24 hours postoperatively, LOV, length of stay in the ICU, and lung function 6 months postoperatively (evaluated with FEV1 in percent).
All recipients had end-stage lung disease; the diagnoses are listed in Table 1.
Table 1. Preoperative characteristics of recipients (median, range)
| Patients Extubated in OR (N = 53) | Patients Extubated in ICU (N = 51) | p | |
|---|---|---|---|
| COPD | 25 | 23* | |
| Emphysema | 13 | 10† | |
| Alpha1-antitrypsin deficiency | 10 | 9 | |
| Pulmonary fibrosis | 4 | 5 | |
| Sarcoidosis | 1 | 2 | |
| Silicosis | 1 | ||
| Sarcoidosis and emphysema | 1 | ||
| Age (y) | 54 (39-66) | 55 (31-67) | 0.93 |
| Sex, male/female | 20/28 | 17/34 | 0.58 |
| Side of transplantation, right/left | 23/25 | 26/25 | 0.99 |
| Preoperative FEV1 (percent of predicted) | 21 (11.0-75.0) | 25 (11.1-67.0) | 0.25 |
| Preoperative PCO2 | 5.76 (4.3-9.4) | 5.75 (2.7-10.0) | 0.51 |
| *One patient died intraoperatively. †Data for one patient is missing. | |||
Before transplantation, the recipients were given their initial immunosuppressive medication and, if needed, 5 to 10 mg of diazepam. In the first 33 patients, anesthetic treatment was based on propofol, midazolam, fentanyl, pancuronium, and intraoperative thoracic epidural analgesia, if no contraindications existed. Oral intubation with a double-lumen tube placed in the left mainstem bronchus was standard. Placement was confirmed with fiberoptic bronchoscopy. Postoperatively, the patients were reintubated with a single-lumen tube for ventilatory support in the ICU. Extubation in the OR was not even considered.
From August 1997, the anesthetic approach was changed. On arrival in the OR, special care was paid to active warming with a hot air warming blanket, even before insertion of a thoracic epidural catheter. If no contraindications were present, an epidural catheter was inserted at 4-6. After testing the epidural catheter with 3 mL of lidocaine/epinephrine, a bolus of bupivacaine 5 mg/mL, 5 to 8 mL, was given. All patients with epidural catheter were given continuous epidural infusion with bupivacaine, 2.5 mg/mL, and morphine, 0.05 mg/mL, up to 6 days postoperatively. Anesthesia was induced and maintained with propofol (induction: 50-150 mg, continuous infusion: 4-8 mg/kg/h, and up to 12 mg/kg/h in case of no epidural) and remifentanil (0.25 μg/kg/min or 0.5 μg/kg/min if epidural were absent). Cisatracurium was used for muscular relaxation. A double-lumen tube was inserted and checked with a fiberoptic bronchoscope.
A central venous catheter was inserted after induction of anesthesia. A pulmonary artery catheter was not used routinely. The recipient received 2 antibiotics, ceftriaxone and fucidin; methylprednisolone; and before unclamping, anti-thymocyte globulin (ATG) infusion was given.
Implantation of the lung was done in the standard manner, through a posterolateral thoracotomy, dividing the latissimus dorsi muscle and all the anastomoses were done with running nonabsorbent 4-0 Prolene sutures, except for the anterior cartilaginous bronchial ring, which was sutured with an interrupted Prolene 4-0 (Johnson and Johnson, Belgium). The bronchial anastomosis was checked with a fiberscope.
After termination of surgery, the possibility of extubation in the OR was evaluated. This included the presence of satisfactory conscious state, acceptable respiration (FIO2 <40%, arterial saturation >94%, and end expiratory PCO2 <8 kPa), acceptable body temperature, and acceptable blood loss. Time of completion of bronchoscopy and time of extubation in the OR or in the ICU were recorded. If extubation was not expected within 30 minutes, no attempts were made in the OR. All extubated or mechanically ventilated patients were moved to the ICU. Length of stay in the ICU in days and in the case of ventilation LOV in hours were registered.
The results are expressed as mean and range. The data were compared by nonparametric Mann-Whitney U test. Statistical significance was defined as p < 0.05.
Results
Data from 106 SLTX were examined (results given as median [range]). Although data were collected retrospectively, 96.7% of all data searched for was found. One patient (0.9%) died intraoperatively because of intractable pulmonary edema and hypoxemia. Fifty-three patients (50%) were extubated in the OR after final postoperative bronchoscopy. Of the 53 patients extubated in the OR, 51 were anesthetized with epidural-propofol-remifentanil, and 2 patients were anesthetized with epidural-propofol-fentanyl. None of the patients without epidural were extubated in the OR. Length of ventilation after surgery for patients extubated in OR was 25 minutes (0-120 minutes). Two patients were ventilated for more than 1 hour in the OR before extubation (Table 2).
Table 2. Anesthetic details
| Patients Extubated in OR | Patients Extubated in ICU | p | |
|---|---|---|---|
| Propofol | 53 (N = 53) | 47 (N = 51) | 0.48 |
| Remifentanil | 50 (N = 53) | 21 (N = 51) | <0.05 |
| Epidural analgesia | 53 (N = 53) | 43 (N = 51) | <0.05 |
| Extracorporeal perfusion | 0 (N = 53) | 4 (N = 51) | 0.49 |
| Inotropes: | 0.78 | ||
| Dopamine | 24 | 30 | |
| Ephedrine | 15 | 8 | |
| Phenylephrine | 0 | 1 | |
| Epinephrine | 1 | 3 | |
| Norepinephrine | 1 | 1 | |
| Dobutamine | 3 | 8 | |
| Nitroglycerin | 1 | 1 | |
| Nitroprusside | 0 | 1 | |
| Length of ventilation after bronchoscopy | 25 min; range 0-120 min | 597min; range 90-27,360 min | <0.001 |
| Length of ischemia | 320 min; range 119-479 min | 318 min; range 122-515 min | 0.98 |
| Length of stay in ICU | 2 days; range 1-23 days | 2 days; range 0-30 days | 0.48 |
Eleven patients extubated in the OR (21%) needed reintubation within 24 hours postoperatively. Reasons for reintubation were respiratory insufficiency (4/11), pulmonary edema (3/11), hemorrhage (2/11), pneumothorax (1/11), and vasovagal reaction (1/11). There were no statistically significant differences in age, sex, preoperative FEV1, preoperative PCO2, mode of transport of graft, trauma of donor, or duration of ischemia between patients needing reintubation and patients who did not need reintubation. Reintubation increased the length of stay in the ICU by 1 day from 2 days (1-23 days) to 3 days (1-21 days) (not significant). FEV1 after 6 months for patients needing reintubation was 42% of predicted (22%-86%) compared with 53% (14%-79%) for patients with no need for reintubation (not significant).
Fifty-two patients were extubated in the ICU. After 24 hours, 9 patients (17%) were still intubated (range, 0-19 days; Fig 1).
Fig. 1.
Extubation rate first 24 hours after the end of surgery.
There were no differences between men and women regarding preoperative FEV1 in percent of predicted. Age and sex did not influence extubation frequency in the OR, reintubation frequency, LOV, length of stay in the ICU, or FEV1 in percent of predicted after 6 months.
Right and left lung were compared, and no significant differences in frequency of extubation in the OR, reintubation within the first 24 postoperative hours, LOV, or length of stay in the ICU were found.
Fifty-three donor lungs were transported by plane, and fifty-three donor lungs by car. This was found not to influence extubation frequency in the OR, reintubation frequency, LOV, length of stay in the ICU, or FEV1 in percent of predicted after 6 months. Duration of ischemia was significantly longer for patients receiving a donor lung transported by air (341 minutes; range, 220-515 minutes) than those transported by car (261 minutes; range, 119-479 minutes). Length of ischemia per se did not influence extubation, frequency of reintubation, LOV, length of stay in the ICU, or FEV1 after 6 months.
To avoid extracorporeal circulation (ECC), permissive hypercapnia was accepted, and only 4 patients (3.8%) needed ECC. None of the patients on ECC were extubated in the OR, although 1 of the 4 patients was extubated within the first 24 hours. LOV was significantly longer (1,545 minutes; range, 1,280-12,960 minutes) than for patients not needing ECC (40 minutes; range, 0-27,360 minutes).
Six months after transplantation, 6 patients had passed away, resulting in a survival rate of 94%. FEV1 in percent of predicted after 6 months was related to preoperative FEV1. Data from 99 patients were found; 93 patients had an increase in FEV1, 2 patients had an unchanged FEV1, and 4 patients had an FEV1 lower than preoperatively (Fig 2).
Fig. 2.
FEV1 after 6 months as a function of preoperative FEV1.
Discussion
The center has performed 106 SLTX from 1993 to 1999. From 1993 to 1997, no patients were extubated in the OR, but, since then, this has been the case in 72% of the patients. This improvement was made possible by the introduction of a new anesthetic technique with the introduction of lung volume–reducing surgery in the authors' department.
Remifentanil, propofol anesthesia combined with epidural analgesia, and strict control of bleeding and normal temperature will ensure conditions suitable for early extubation in most SLTX patients. It is not always possible to predict which patients will be able to be extubated in the OR. Reasons not to extubate in the OR are hypothermia, respiratory problems such as pulmonary edema and hypercapnia, or simply tradition. None of the patients without epidural analgesia were extubated in the OR, and they were intubated significantly longer than patients with epidural analgesia.
The fact that patients in good condition can be extubated in the OR with success should not lead to the misinterpretation that early extubation creates a stable patient. Twenty-one percent of the patients had to be reintubated within 24 hours. Three patients were reintubated because of surgical complications, 3 patients because of pulmonary edema, and 4 because of respiratory insufficiency. The number of patients needing reintubation raises the following question: Is too-early extubation after SLTX a problem? Reintubation is a potentially hazardous procedure to the patient, and the possible risk of reintubation should be evaluated carefully before extubation in the OR. No significant differences were found between the group of patients who needed reintubation and patients who did not need reintubation concerning length of stay in the ICU or FEV1 after 6 months, which indicates that the need of reintubation does not directly harm the patients.
In the present study, the authors looked for factors disposing for graft dysfunction immediately postoperatively and after 6 months. The possibility for extubation and frequency of reintubation was not influenced by mode of transport of the graft, sex, weight, or age of the recipient. The mode of transport of the graft was examined because flying could theoretically induce a volume trauma to the graft. However, this was not confirmed in this investigation. Time of cold graft ischemia did not influence graft function postoperatively or after 6 months, as reported by Christie et al12 and Fiser et al.13 The strongest predictor of lung function (% predicted FEV1) after 6 months was the preoperative percent of predicted FEV1. Whether this is because of better function of the genuine lung or an expression of good muscular function is not known.
In conclusion, extubation in the OR after SLTX is an option to be considered in selected cases. However, a reintubation frequency of 21% still emphasizes the importance of evaluation of each case before extubation in the OR. The present study shows that the authors have gained control over the time of extubation. The study also shows that this control should be used to secure extubation, not always minutes after the end of surgery but sometimes within 1 to 2 hours in the ICU. In this department, the authors will continue to extubate patients in the OR if the following conditions are present: (1) there is spontaneous ventilation with good oxygenation (FIO2 <40%, saturation >94%), (2) the patient is fully awake, and (3) there is no bleeding. All other cases will be transferred to the ICU for a short observation period before extubation.
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☆ Address reprint requests to Lise Nørrekjær Hansen, MD, Hostrups Have 7, 3th, 1954 Frederiksberg, Denmark. E-mail: norrekjaer@dadlnet.dk
PII: S1053-0770(02)47707-5
doi:10.1053/jcan.2003.7
© 2003 Published by Elsevier Inc.
Volume 17, Issue 1 , Pages 36-39, February 2003
