To the Editor:
Arora and colleagues examined time to extubation after thoracic aortic surgery.
1
In their very interesting study, they found negligible differences in median times to extubation between normothermic patients (7 minutes [95% confidence interval (CI) 6-to-8 minutes]) versus hypothermic patients (8 minutes [95% confidence interval 7-to-12 minutes]).- Arora H
- Encarnacion JA
- Li Q
- et al.
Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
J Cardiothorac Vasc Anesth. 2022; ([e-pub ahead of print]) (Accessed September 24, 2022)https://doi.org/10.1053/j.jvca.2022.09.077
1
There were significantly greater incidences of prolonged times to extubation among hypothermic patients (hazard ratio 2.06 [95% confidence interval 1.18-to-3.59]).- Arora H
- Encarnacion JA
- Li Q
- et al.
Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
J Cardiothorac Vasc Anesth. 2022; ([e-pub ahead of print]) (Accessed September 24, 2022)https://doi.org/10.1053/j.jvca.2022.09.077
1
The authors’ study of hypothermia and prolonged extubation is novel because earlier studies involved prolonged extubations being caused by drugs with slower wakeup- Arora H
- Encarnacion JA
- Li Q
- et al.
Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
J Cardiothorac Vasc Anesth. 2022; ([e-pub ahead of print]) (Accessed September 24, 2022)https://doi.org/10.1053/j.jvca.2022.09.077
2
, 3
, 4
or anesthesia providers (nurse anesthetists and resident physicians) who had little prior experience (<5 cases) working with the surgeon.5
The authors’ finding of negligible difference in median times to extubation but large difference in incidences of prolonged times to extubation matched a two-group comparison of patients undergoing long gynecologic procedures.4
There was prolonged extubation among 39% (292/740) of patients who did not receive remifentanil or desflurane versus 6% (35/632) among those who did (relative risk 7.12 [95% confidence interval 5.10, 9.95]), but the mean difference was only 1 minute.4
Arora and colleagues explained that “although there are no established limits that clearly define normal time to extubation, prolonged times to extubation that are greater than 15 minutes can significantly reduce operating room workflow, with other team members sitting idle waiting for extubation,” referencing Bayman and colleagues’ study which showed, instead, that prolonged operative times to extubation were not a useful metric for comparing the performance of individual anesthesia providers or anesthesiologists.
6
The study of operating room workflow described by Arora and colleagues1
was done by Masursky and colleagues.- Arora H
- Encarnacion JA
- Li Q
- et al.
Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
J Cardiothorac Vasc Anesth. 2022; ([e-pub ahead of print]) (Accessed September 24, 2022)https://doi.org/10.1053/j.jvca.2022.09.077
7
There was a positive association between time to extubation and the probability of at least one person being idle in the operating room.7
There are more data showing the validity of using 15 minutes as criterion for prolonged time to extubation. Among many hospital patients, approximately 15% of extubations were prolonged based on 15 minutes.
2
,7
Patients with prolonged extubations (≥15 minutes) were rated by the anesthesiologists as having poor recovery from anesthesia.8
Extubation times longer than 15 minutes were also associated with immediate reintubation and with respiratory treatments in the post anesthesia care unit.9
Times to extubation ≥15 minutes were associated with longer times from patient transport from the operating room to the start of the surgeon's next case.2
Finally, when controlling for surgical time and prone positioning,6
prolonged extubations were associated with 13-minute longer times from end of surgery to operating room exit.10
Declaration of Interest
The Division of Management Consulting of the University of Iowa's Department of Anesthesia provides consultations to corporations, hospitals, and individuals. I receive no funds personally other than my salary and allowable expense reimbursements from the University of Iowa, and have tenure with no incentive program. My family and I have no financial holdings in any company related to my work, other than indirectly through mutual funds for retirement. Income from the Division's consulting work including those related to the economics of time to extubation are used to fund Division research. A list of all the Division's consults is available in my posted curriculum vitae at https://FranklinDexter.net/Contact_Info.htm.
Acknowledgements
None.
Funding
This letter to the editor did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
REFERENCES
- Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.J Cardiothorac Vasc Anesth. 2022; ([e-pub ahead of print]) (Accessed September 24, 2022)https://doi.org/10.1053/j.jvca.2022.09.077
- Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane.Anesth Analg. 2010; 110: 570-580
- Meta-analysis of average and variability of time to extubation comparing isoflurane with desflurane or isoflurane with sevoflurane.Anesth Analg. 2010; 110: 1433-1439
- Comparison of percentage prolonged times to tracheal extubation between a Japanese teaching hospital and one in the United States, without and with a phase I post-anesthesia care unit.Anesth Analg. 2021; 133: 1206-1214
- Prolonged tracheal extubation time after glioma surgery was associated with lack of familiarity between the anesthesia provider and the operating neurosurgeon. A retrospective, observational study.J Clin Anesth. 2020; 60: 118-124
- Prolonged operative time to extubation is not a useful metric for comparing the performance of individual anesthesia providers.Anesthesiology. 2016; 124: 322-338
- Measure to quantify the influence of time from end of surgery to tracheal extubation on operating room workflow.Anesth Analg. 2012; 115: 402-406
- The initial clinical experience of 1819 physicians in maintaining anesthesia with propofol: Characteristics associated with prolonged time to awakening.Anesth Analg. 1993; 77: S10-S14
- Prolonged time to extubation after general anaesthesia is associated with early escalation of care: A retrospective observational study.Eur J Anaesthesiol. 2021; 38: 504
- Increased mean time from end of surgery to operating room exit in a historical cohort of cases with prolonged time to extubation.Anesth Analg. 2013; 117: 1453-1459
Article info
Publication history
Published online: October 08, 2022
Footnotes
Letter to the Editor about Arora H, Encarnacion JA, Li Q, et al. Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery. doi: 10.1053/j.jvca.2022.09.077.
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- Hypothermia and Prolonged Time From Procedure End to Extubation After Endovascular Thoracic Aortic SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 12
- PreviewPerioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients.
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