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Earlier studies of prolonged times to tracheal extubation after end of surgery

Published:October 08, 2022DOI:https://doi.org/10.1053/j.jvca.2022.09.099
      To the Editor:
      Arora and colleagues examined time to extubation after thoracic aortic surgery.
      • Arora H
      • Encarnacion JA
      • Li Q
      • et al.
      Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
      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.
      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.
      The authors’ study of hypothermia and prolonged extubation is novel because earlier studies involved prolonged extubations being caused by drugs with slower wakeup
      • Dexter F
      • Bayman EO
      • Epstein RH.
      Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane.
      • Agoliati A
      • Dexter F
      • Lok J
      • et al.
      Meta-analysis of average and variability of time to extubation comparing isoflurane with desflurane or isoflurane with sevoflurane.
      • Sugiyama D
      • Dexter F
      • Thenuwara K
      • et al.
      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.
      or anesthesia providers (nurse anesthetists and resident physicians) who had little prior experience (<5 cases) working with the surgeon.
      • Epstein RH
      • Dexter F
      • Cajigas I
      • et al.
      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.
      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.
      • Sugiyama D
      • Dexter F
      • Thenuwara K
      • et al.
      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.
      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.
      • Sugiyama D
      • Dexter F
      • Thenuwara K
      • et al.
      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.
      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.
      • Bayman EO
      • Dexter F
      • Todd MM.
      Prolonged operative time to extubation is not a useful metric for comparing the performance of individual anesthesia providers.
      The study of operating room workflow described by Arora and colleagues
      • Arora H
      • Encarnacion JA
      • Li Q
      • et al.
      Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
      was done by Masursky and colleagues.
      • Masursky D
      • Dexter F
      • Kwakye MO
      • et al.
      Measure to quantify the influence of time from end of surgery to tracheal extubation on operating room workflow.
      There was a positive association between time to extubation and the probability of at least one person being idle in the operating room.
      • Masursky D
      • Dexter F
      • Kwakye MO
      • et al.
      Measure to quantify the influence of time from end of surgery to tracheal extubation on operating room workflow.
      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.
      • Dexter F
      • Bayman EO
      • Epstein RH.
      Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane.
      ,
      • Masursky D
      • Dexter F
      • Kwakye MO
      • et al.
      Measure to quantify the influence of time from end of surgery to tracheal extubation on operating room workflow.
      Patients with prolonged extubations (≥15 minutes) were rated by the anesthesiologists as having poor recovery from anesthesia.
      • Apfelbaum JL
      • Grasela TH
      • Jr Hug CC
      • et al.
      The initial clinical experience of 1819 physicians in maintaining anesthesia with propofol: Characteristics associated with prolonged time to awakening.
      Extubation times longer than 15 minutes were also associated with immediate reintubation and with respiratory treatments in the post anesthesia care unit.
      • Vannucci A
      • Riordan IR
      • Prifti K
      • et al.
      Prolonged time to extubation after general anaesthesia is associated with early escalation of care: A retrospective observational study.
      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.
      • Dexter F
      • Bayman EO
      • Epstein RH.
      Statistical modeling of average and variability of time to extubation for meta-analysis comparing desflurane to sevoflurane.
      Finally, when controlling for surgical time and prone positioning,
      • Bayman EO
      • Dexter F
      • Todd MM.
      Prolonged operative time to extubation is not a useful metric for comparing the performance of individual anesthesia providers.
      prolonged extubations were associated with 13-minute longer times from end of surgery to operating room exit.
      • Dexter F
      • Epstein RH.
      Increased mean time from end of surgery to operating room exit in a historical cohort of cases with prolonged time to extubation.

      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.

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        Hypothermia and prolonged time from procedure end to extubation after endovascular thoracic aortic surgery.
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