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Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative.

ABSTRACT: OBJECTIVE:Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery. METHODS:We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 in hospitals participating in the Vascular Quality Initiative (VQI). Our primary outcome was prolonged LOS (>7 days), and the secondary outcome was respiratory complications (pneumonia or reintubation). The association between extubation timing and outcomes was assessed using multivariable logistic regression mixed-effects models that adjusted for confounding factors at the patient and procedure level. A variable importance analysis was conducted using a chi-pie framework to identify factors contributing to the variability of extubation timing. RESULTS:The 7171 patients undergoing abdominal aortic surgery were a mean age of 65.4 (standard deviation, 10.2) years, and 63% were male. Extubation occurred (1) in the operating room (76.3%), (2) <12 hours (10.9%), (3) 12 to 24 hours (7.2%), or (4) >24 hours (5.6%) after surgery. Hospitals in the top quartile for case volume had the highest percentage of patients extubated in the operating room (82.8%). Patients least likely to be extubated in the operating room were older, more likely to have chronic obstructive pulmonary disease, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS (<12 hours: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; 12-24 hours: OR, 2.1; 95% CI, 1.7-2.7; >24 hours: OR, 5.3; 95% CI, 4.0-6.9), and pulmonary complications (<12 hours: OR, 1.9; 95% CI, 1.4-2.6; 12-24 hours: OR, 2.6; 95% CI, 1.8-3.6; >24 hours: OR, 9.6; 95% CI, 7.1-13.0) compared with those extubated in the operating room. Subset analysis of patients extubated in the operating room or <12 hours showed that extubation out of the operating room was associated with prolonged LOS (OR, 1.4; 95% CI, 1.2-1.7) and pulmonary complications (OR, 1.8; 95% CI, 1.3-2.5). The variable importance analysis demonstrated that EBL (26%) and procedure time (24%) accounted for half of the variation in extubation timing. CONCLUSIONS:Extubation in the operating room is associated with shorter LOS and morbidity after open aortic surgery. EBL, procedure time, and center variation account for variability in extubation timing. These data advocate for standardized perioperative respiratory care to reduce variation, improve outcomes, and reduce LOS.

SUBMITTER: David RA

PROVIDER: S-EPMC6114133 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative.

David Ramoncito A RA Brooke Benjamin S BS Hanson Kristine T KT Goodney Philip P PP Genovese Elizabeth A EA Baril Donald T DT Gloviczki Peter P DeMartino Randall R RR

Journal of vascular surgery 20170331 1

<h4>Objective</h4>Timing of extubation after open aortic procedures varies across hospitals. This study was designed to examine extubation timing and determine its effect on length of stay (LOS) and respiratory complications after elective open aortic surgery.<h4>Methods</h4>We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (2687 [37.5%]) or suprainguinal bypass for aortoiliac occlusive disease (4484 [62.5%]) from October 2010 to April 2015 ...[more]

PMID: 28366307

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Project description:BackgroundAortic cross-clamp utilized during cardiac surgery facilitates motionless and bloodless surgical field. However, the duration of clamp time has an inverse effect on early post-operative recovery period. In this study, we sought to examine the predictors of aortic clamp duration and intensive care unit length of stay.ResultsSix hundred and nine adult patients presented for elective cardiac surgery between December 2019 and December 2020 were enrolled. The age of patients ranged from 18 to 82 years (mean 55.62 years, SD ± 12.3 years). Male/female ratio is 4.6:1. Most patients (87.2%) were planned for coronary artery bypass grafting (CABG) and 78 patients (12.8%) for single heart valve procedure. Operative time (OT) ranged from 120 to 402 min and averaged 259.4 min (SD ± 45.9 min). ACC time ranged from 15 to 159 min and averaged 50.56 min (SD ± 19.4 min). Factors associated with significantly longer ACCT were: smoking (OR = 1.89 (95% CI 1.3-2.74), p value = 0.01), respiratory disease (OR = 0.48 (95% CI 0.24-0.96), p value = 0.039), obesity (OR = 1.76 (95% CI 1.18-2.63), p value = 0.005) and AVR (OR = 2.11 (95% CI 1.17-3.83), p value = 0.013). Low cardiac output syndrome (LCOS) was observed in 19.2% of patients. Longer than average ACCT was associated with increased use of inotropes (p value < 0.001), intra-aortic balloon pump (p value < 0.001) and first 24 h post-operative blood loss (p value < 0.001). The average intensive care unit length of stay (ICULOS) was 1.64 days (SD ± 1.1 days). Patients' ACCT converged positively and significantly on ICULOS (Beta coefficient = 1.013 (95% CI 1.01-1.015), p value < 0.001).ConclusionAortic cross-clamping is a crucial method in cardiac surgery to achieve motionless field; however, prolongation of this method had an incremental risks for the development of low cardiac output syndrome, increased first 24 h post-operative blood loss and longer stay in the intensive care unit.

Project description:BackgroundEarly extubation after cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (endovascular aneurysm repair [EVAR], 77%-97%; open repair, 30%-70%) after repair of intact abdominal aortic aneurysms (AAAs). However, the effects of extubation practices on patient outcomes after repair of AAAs are unclear.MethodsAll patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003 to 2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (operating room, <12 hours, >12 hours) and open repair (operating room, <12 hours, 12-24 hours, >24 hours). Prolonged hospital stay was defined as >2 days after EVAR and >7 days after open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified.ResultsThere were 5774 patients evaluated (EVAR, 4453; open repair, 1321). After both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12-hour delay in extubation: respiratory (EVAR: odds ratio [OR], 4.3 [95% confidence interval (CI), 3.0-6.1]; open repair: OR, 1.8 [95% CI, 1.5-2.2]), prolonged hospital stay (EVAR: OR, 2.7 [95% CI, 2.0-3.8]; open repair: OR, 1.3 [95% CI, 1.1-1.4]), and discharge to SNF (EVAR: OR, 2.0 [95% CI, 1.5-2.8]; open repair: OR, 1.4 [95% CI, 1.1-1.6]). Predictors of extubation outside of the operating room after EVAR included increasing age (OR, 1.5; 95% CI, 1.2-1.8), congestive heart failure (OR, 1.9; 95% CI, 1.2-3.0), chronic obstructive pulmonary disease (OR, 2.0; 95% CI, 1.4-2.9), symptomatic aneurysm (OR, 3.8; 95% CI, 2.3-5.7), and increasing diameter (OR, 1.01; 95% CI, 1.01-1.01). After open repair, increasing age (OR, 1.4; 95% CI, 1.1-1.6), congestive heart failure (OR, 1.8; 95% CI, 1.01-3.3), dialysis (OR, 2.8; 95% CI, 1.7-70), symptomatic aneurysm (OR, 2.8; 95% CI, 1.9-4.3), and hospital practice patterns (OR, 1.01; 95% CI, 1.01-1.01) were predictive of extubation outside of the operating room.ConclusionsThe benefits of early extubation in cardiac patients are also seen after AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to an SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and to improve patient outcomes.

Project description:BackgroundIn the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery.MethodsWe employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively.Results779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge.ConclusionsPatient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

Project description:ObjectiveHeart rate (HR) parameters are known indicators of cardiovascular complications after cardiac surgery, but there is little evidence of their role in predicting outcome after major vascular surgery. The purpose of this study was to determine whether arrival HR (AHR) and highest intraoperative HR are associated with mortality or major adverse cardiac events (MACEs) after elective vascular surgery in the Vascular Quality Initiative (VQI).MethodsPatients undergoing elective lower extremity bypass (LEB), aortofemoral bypass (AFB), and open abdominal aortic aneurysm (AAA) repair in the VQI were analyzed. MACE was defined as any postoperative myocardial infarction, dysrhythmia, or congestive heart failure. Controlled HR was defined as AHR <75 beats/min on operating room arrival. Delta HR (DHR) was defined as highest intraoperative HR - AHR. Procedure-specific MACE models were derived for risk stratification, and generalized estimating equations were used to account for clustering of center effects. HR, beta-blocker exposure, cardiac risk, and their interactions were explored to determine association with MACE or 30-day mortality. A Bonferroni correction with P < .004 was used to declare significance.ResultsThere were 13,291 patients reviewed (LEB, n = 8155 [62%]; AFB, n = 2629 [18%]; open AAA, n = 2629 [20%]). Rates of any preoperative beta-blocker exposure were as follows: LEB, 66.5% (n = 5412); AFB, 57% (n = 1342); and open AAA, 74.2% (n = 1949). AHR and DHR outcome association was variable across patients and procedures. AHR <75 beats/min was associated with increased postoperative myocardial infarction risk for LEB patients across all risk strata (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.03-1.9; P = .03), whereas AHR <75 beats/min was associated with decreased dysrhythmia risk (OR, 0.42; 95% CI, 0.28-0.63; P = .0001) and 30-day death (OR, 0.50; 95% CI, 0.33-0.77; P = .001) in patients at moderate and high cardiac risk. These HR associations disappeared in controlling for beta-blocker status. For AFB and open AAA repair patients, there was no significant association between AHR and MACE or 30-day mortality, irrespective or cardiac risk or beta-blocker status. DHR and extremes of highest intraoperative HR (>90 or 100 beats/min) were analyzed among all three operations, and no consistent associations with MACE or 30-day mortality were detected.ConclusionsThe VQI AHR and highest intraoperative HR variables are highly confounded by patient presentation, operative variables, and beta-blocker therapy. The discordance between cardiac risk and HR as well as the lack of consistent correlation to outcome makes them unreliable predictors. The VQI has elected to discontinue collecting AHR and highest intraoperative HR data, given insufficient evidence to suggest their importance as an outcome measure.

Dataset Information

Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative.

Publications

Early extubation is associated with reduced length of stay and improved outcomes after elective aortic surgery in the Vascular Quality Initiative.

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