Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Biinstitutional Study

Published:November 26, 2021DOI:


      It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery.


      A retrospective, observational study.


      Two university-affiliated tertiary care centers.


      A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR).



      Measurements and Main Results

      A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk.


      Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.

      Key Words

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        • Ramachandran SK
        • Nafiu OO
        • Ghaferi A
        • et al.
        Independent predictors and outcomes of unanticipated early postoperative tracheal intubation after nonemergent, noncardiac surgery.
        Anesthesiology. 2011; 115: 44-53
        • Johnson RG
        • Arozullah AM
        • Neumayer L
        • et al.
        Multivariable predictors of postoperative respiratory failure after general and vascular surgery: Results from the patient safety in surgery study.
        J Am Coll Surg. 2007; 204: 1188-1198
        • Brovman EY
        • Steen TL
        • Urman RD.
        Associated risk factors and complications in vascular surgery patients requiring unplanned postoperative reintubation.
        J Cardiothorac Vasc Anesth. 2017; 31: 554-561
        • Hua M
        • Brady JE
        • Li G.
        A scoring system to predict unplanned intubation in patients having undergone major surgical procedures.
        Anesth Analg. 2012; 115: 88-94
        • Brueckmann B
        • Villa-Uribe JL
        • Bateman BT
        • et al.
        Development and validation of a score for prediction of postoperative respiratory complications.
        Anesthesiology. 2013; 118: 1276-1285
        • Cheng DC
        • 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: 1300-1310
        • Arenson BG
        • MacDonald LA
        • Grocott HP
        • et al.
        Effect of intensive care unit environment on in-hospital delirium after cardiac surgery.
        J Thorac Cardiovasc Surg. 2013; 146: 172-178
        • Borracci RA
        • Ochoa G
        • Ingino CA
        • et al.
        Routine operation theatre extubation after cardiac surgery in the elderly.
        Interact Cardiovasc Thorac Surg. 2016; 22: 627-632
        • Hawkes CA
        • Dhileepan S
        • Foxcroft D.
        Early extubation for adult cardiac surgical patients.
        Cochrane Database Syst Rev. 2003; CD003587
        • Goeddel LA
        • Hollander KN
        • Evans AS.
        Early extubation after cardiac surgery: A better predictor of outcome than metric of quality?.
        J Cardiothorac Vasc Anesth. 2018; 32: 745-747
        • Acheampong D
        • Guerrier S
        • Lavarias V
        • et al.
        Unplanned postoperative reintubation following general and vascular surgical procedures: Outcomes and risk factors.
        Ann Med Surg. 2018; 33: 40-43
        • Candela-Toha A
        • Arribas-Perez P
        • Samaranch-Palero N
        • et al.
        Risk factors and outcome of reintubation after cardiac surgery: 12AP6-7.
        Eur J Anaesthesiol. 2013; 30: 198-199
        • Rujirojindakul P
        • Geater AF
        • McNeil EB
        • et al.
        Risk factors for reintubation in the post-anaesthetic care unit: A case-control study.
        Br J Anaesth. 2012; 109: 636-642
        • Beverly A
        • Brovman EY
        • Malapero RJ
        • et al.
        Unplanned reintubation following cardiac surgery: Incidence, timing, risk factors, and outcomes.
        J Cardiothorac Vasc Anesth. 2016; 30: 1523-1529
        • Brovman EY
        • Kuo C
        • Lekowski RW
        • et al.
        Outcomes after transcatheter aortic valve replacement: A propensity matched retrospective cohort study.
        J Cardiothorac Vasc Anesth. 2018; 32: 2169-2175
        • Austin PC
        • Steyerberg EW.
        Events per variable (EPV) and the relative performance of different strategies for estimating the out-of-sample validity of logistic regression models.
        Stat Methods Med Res. 2017; 26: 796-808
        • Peduzzi P
        • Concato J
        • Feinstein AR
        • et al.
        Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates.
        J Clin Epidemiol. 1995; 48: 1503-1510
        • Vittinghoff E
        • McCulloch CE.
        Relaxing the rule of ten events per variable in logistic and Cox regression.
        Am J Epidemiol. 2007; 165: 710-718
        • Djaiani GN
        • Ali M
        • Heinrich L
        • et al.
        Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery.
        J Cardiothorac Vasc Anesth. 2001; 15: 152-157
        • Liu FL
        • Cherng YG
        • Chen SY
        • et al.
        Postoperative recovery after anesthesia in morbidly obese patients: A systematic review and meta-analysis of randomized controlled trials.
        Can J Anesth. 2015; 62: 907-917
        • Brovman EY
        • Gabriel RA
        • Lekowski RW
        • et al.
        Rate of major anesthetic-related outcomes in the intraoperative and immediate postoperative period after cardiac surgery.
        J Cardiothorac Vasc Anesth. 2016; 30: 338-344
        • Arom KV
        • Emery RW
        • Petersen RJ
        • et al.
        Cost-effectiveness and predictors of early extubation.
        Ann Thorac Surg. 1995; 60: 127-132
        • Subira C
        • Hernandez G
        • Vazquez A
        • et al.
        Effect of pressure support vs t-piece ventilation strategies during spontaneous breathing trials on successful extubation among patients receiving mechanical ventilation: A randomized clinical trial.
        JAMA. 2019; 321: 2175-2182
        • Perren A
        • Domenighetti G
        • Mauri S
        • et al.
        Protocol-directed weaning from mechanical ventilation: Clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation.
        Intensive Care Med. 2002; 28: 1058-1063
        • Penuelas O
        • Frutos-Vivar F
        • Fernandez C
        • et al.
        Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation.
        Am J Respir Crit Care Med. 2011; 184: 430-437
        • Stewart RA
        • Szalewska D
        • She L
        • et al.
        Exercise capacity and mortality in patients with ischemic left ventricular dysfunction randomized to coronary artery bypass graft surgery or medical therapy: An analysis from the STICH trial (Surgical Treatment for Ischemic Heart Failure).
        JACC Heart Fail. 2014; 2: 335-343
        • McCann M
        • Stamp N
        • Ngui A
        • et al.
        Cardiac prehabilitation.
        J Cardiothorac Vasc Anesth. 2019; 33: 2255-2265
        • Engelman DT
        • Ben Ali W
        • Williams JB
        • et al.
        Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations.
        JAMA Surg. 2019; 154: 755-766
        • Pieri M
        • Belletti A
        • Monaco F
        • et al.
        Outcome of cardiac surgery in patients with low preoperative ejection fraction.
        BMC Anesth. 2016; 16: 97
        • Seese L
        • Sultan I
        • Gleason T
        • et al.
        Outcomes of conventional cardiac surgery in patients with severely reduced ejection fraction in the modern era.
        Ann Thorac Surg. 2020; 109: 1409-1418
        • Swaminathan RV
        • Feldman DN
        • Pashun RA
        • et al.
        Gender differences in in-hospital outcomes after coronary artery bypass grafting.
        Am J Cardiol. 2016; 118: 362-368
        • Blankstein R
        • Ward RP
        • Arnsdorf M
        • et al.
        Female gender is an independent predictor of operative mortality after coronary artery bypass graft surgery: Contemporary analysis of 31 Midwestern hospitals.
        Circulation. 2005; 112: i323-i327
        • Brown ML
        • Lenoch JR
        • Schaff HV.
        Variability in data: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database.
        J Thorac Cardiovasc Surg. 2010; 140: 267-273
        • Shahian DM
        • O'Brien SM
        • Filardo G
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: Part 1–coronary artery bypass grafting surgery.
        Ann Thorac Surg. 2009; 88: s2-22

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      • Early But Prudent
        Journal of Cardiothoracic and Vascular Anesthesia
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          WE READ with interest the recent study by Brovman et al describing fast-track protocols in cardiac anesthesia.1 The authors concluded that early extubation does not entail significant reintubation risk following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), as they achieved an early extubation in 34.5% of CABG and 47.7% of AVR patients.1 A thorough evaluation of comorbidities may have provided useful insights into the ability to perform successful early extubation.1,2 The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was not included in the index analysis, the importance of the former being emphasized by Shoji et al.
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