ª 2024 by The Society of Thoracic Surgeons 0003-4975/$36.

00 87
Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2023.09.031

Coronary: Research

CARDIOTHORACIC ANESTHESIOLOGY:

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Routine Extubation in the Operating Room

After Isolated Coronary Artery Bypass
Les James, MD, MPH,1 Deane E. Smith, MD,1 Aubrey C. Galloway, MD,1 Darien Paone, MD,1
Michael Allison, MBA,1 Shashwat Shrivastava, MD,1 Mikhail Vaynblat, MD,1
Daniel G. Swistel, MD,1 Didier F. Loulmet, MD,1 Eugene A. Grossi, MD,1
Mathew R. Williams, MD,1 and Elias Zias, MD1

ABSTRACT

BACKGROUND The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well
established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this
strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs
ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG).

METHODS The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency
isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation
were compared.

RESULTS Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG;
891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity
matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in
incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure,
or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter post-
operative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home
(97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P [ .04).

CONCLUSIONS Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after
nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation
for nonemergency CABG is indicated.

(Ann Thorac Surg 2024;117:87-95)

ª 2024 by The Society of Thoracic Surgeons. Published by Elsevier Inc.

T he value of fast-track extubation in the inten-

sive care unit (ICU) after cardiac surgery has
been well established, and this approach is
associated with reduced ICU and postoperative hospital
length of stay (LOS), reduced pulmonary complications,
and lower costs, with no increased risk of morbidity and
mortality.1-8 As hospitals have sought to curtail costs
and emphasize value-based health care, fast-track ICU
extubation has received increased focus and has become
the standard of care in most centers.9-11 Prolonged

Accepted for publication Sep 18, 2023.

Presented at the Second Annual Meeting of The Society of Thoracic Surgeons Coronary Conference, Miami, FL, Jun 3-4, 2023.
1
Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
Address correspondence to Dr Galloway, Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, 530 1st Ave, Ste 9V, New York,
NY 10016; email: aubrey.galloway@nyulangone.org.
88 JAMES ET AL
SAFETY OF OR EXTUBATION AFTER CABG
Abbreviations and Acronyms
BMI [ body mass index
CABG [ coronary artery bypass grafting
CPB [ cardiopulmonary bypass
EF [ ejection fraction
IABP [ intraaortic balloon pump
ICU [ intensive care unit
IQR [ interquartile range
LOS [ length of stay
OPCAB [ off-pump coronary artery bypass
OR [ operating room
POAF [ postoperative atrial fibrillation
STS [ The Society of Thoracic Surgeons
TIA [ transient ischemic attack
XC [ cross-clamp
intubation, defined as ventilator time greater than 24
hours, is associated with poor outcomes. This associa-
tion led The Society of Thoracic Surgeons (STS) to desig-
nate prolonged intubation a negative cardiac surgery
quality metric.12,13
Several studies have investigated extubation in the
operating room (OR) after cardiac surgery, although
most of these reports have been limited to select pa-
tient populations, such as patients undergoing off-
pump coronary artery bypass (OPCAB) or minimally
invasive cardiac procedures not requiring cardiopul-
monary bypass (CPB) or full sternotomy (ie, minimally
invasive coronary artery bypass).14-16 A multicenter
study of patients who underwent isolated coronary
artery bypass grafting (CABG), primarily OPCAB, found
that OR extubation was associated with shorter ICU
and postoperative hospital LOS, and the reintubation
rate was less than 1%.17 However, relatively few reports
have evaluated routine OR extubation in patients
undergoing CABG with CPB. Using preoperative and
operative variables from their institutional
database, Badhwar and colleagues18 performed
propensity-matched analysis of 652 consecutive pa-
tients who underwent various cardiac operations; 165
patients were extubated in the OR, and 487 patients
were extubated in the ICU. These investigators found
no difference in operative mortality between OR-
extubated and ICU-extubated patients, but OR-extubated
patients had shorter ICU hours and postoperative hospi-
tal LOS, reduced hospital costs, and an increased fre-
quency of direct-to-home discharge.
A randomized controlled trial of 50 OR-extubated
patients and 50 ICU-extubated patients demonstrated
that when combined with the use of low-dose nar-
cotics, restrictive extubation criteria, and shared deci-
sion making by surgeons and anesthesiologists, OR
extubation was safe in carefully selected patients and
was not associated with an increased risk of reintu-
bation.19 Recently, a 10-year retrospective propensity-
matched analysis from the Virginia Cardiac Services
Ann Thorac Surg
2024;117:87-95
Quality Initiative database of patients who underwent
nonemergency isolated CABG or isolated valve surgery
compared 487 OR-extubated patients with 899 ICU-
extubated patients.20 There was no difference in
operative mortality between OR-extubated and ICU-
extubated patients. However, whereas OR-extubated
patients had shorter hospital LOS and lower hospital
costs, they also had a higher incidence of post-
operative reintubation and reoperation for bleeding.20
Thus, although the feasibility of OR extubation has
been demonstrated in select patients undergoing
CABG, the appropriate recommendations for its
widespread adoption remain uncertain.
This study was performed to compare perioperative
outcomes between OR-extubated and ICU-extubated
patients who underwent nonemergency, isolated
CABG over a 6-year period. ICU extubation was the pri-
mary strategy in the first 3 years of the study, with OR
extubation gradually supplanting this approach during
the last 3 years. We hypothesized that routine OR extu-
bation is safe and feasible for patients undergoing
nonemergency, isolated CABG and would not be associ-
ated with an increase in perioperative morbidity or
mortality.
PATIENTS AND METHODS
DATA SOURCE. This study was designed to evaluate
perioperative outcomes in patients undergoing
nonemergency, isolated CABG who were extubated in
the ICU compared with patients extubated in the OR.
STS Adult Cardiac Surgery Database files for all patients
who underwent isolated CABG at the NYU Langone
Hospital (New York, NY) between January 1, 2017 and
December 31, 2022 were compiled into a single data file.
STS This study was approved by the NYU Langone Health
a Institutional Review Board (#i23-00450), and the
requirement for written informed consent was waived
because of the retrospective design of the study and the
use of deidentified data.
PATIENT POPULATION. The data file was queried for all
isolated CABG operations by using the STS procedural
definition. Patients who underwent combined valve-
CABG operations, reoperative CABG, CABG with
combined mechanical circulatory support (eg,
extracorporeal membrane oxygenation or Impella
device [Abiomed]), and emergency procedures were
excluded. Patients with missing procedural data or
incomplete data on postoperative ventilation time or
and reintubation were also excluded.
PATIENT SELECTION FOR EXTUBATION STRATEGY. Our
institutional approach to extubation evolved over the
study period. Between 2017 and 2019, our primary goal
was to extubate patients within 6 to 8 hours of ICU arrival.
Ann Thorac Surg JAMES ET AL 89
2024;117:87-95 SAFETY OF OR EXTUBATION AFTER CABG

TABLE 1 Patient Selection

narcotic agents, which were limited to use during
induction, and the preferential use of intravenous
Before After acetaminophen for pain control and propofol for
Propensity Propensity
Matching Matching sedation. The overall goals were to prepare the patient
Group n % n % to be breathing spontaneously by the time of chest
OR-extubated patients 506 36.2 414 50.0 closure and to extubate the patient shortly after
ICU-extubated patients 891 63.8 414 50.0 completion of skin closure.

DEMOGRAPHICS AND BASELINE PATIENT VARIABLES. Base-

ICU, intensive care unit; OR, operating room.
In January 2020, we implemented a strategy wherein all
patients undergoing nonemergency, isolated CABG were
considered candidates for OR extubation. A collaborative
approach between the anesthesiologist and the surgeon
was critical to determine patient suitability for OR extu-
bation, and the plan and any potential issues were
reviewed during the preprocedural timeout. Agreement
between the anesthesiologist and the surgeon was
required to proceed with OR extubation. Intraoperatively,
hemodynamic instability during CPB termination, the
need for significant inotropic support or mechanical cir-
culatory support, and considerable bleeding with ongoing
coagulopathy were considered potential contraindications
to OR extubation, and the decision to defer extubation
until after ICU arrival and stabilization was made at the
discretion of the surgeon or anesthesiologist.
ANESTHESIA FOR PLANNED OPERATING
EXTUBATION. A balanced anesthetic strategy was adop-
ted to facilitate OR extubation. This included low-dose
line demographics included age, race, sex, body mass in-
dex (BMI), STS risk score, and STS prolonged ventilation
score. Patient comorbidities included diabetes, hyperten-
sion, chronic kidney disease with the need for dialysis, and
cerebrovascular disease. Ejection fraction (EF) was
assessed as a preoperative continuous variable. Aortic
cross-clamp (XC) and total CPB time as measured
intraoperatively were assessed as continuous variables.
The need for preoperative or intraoperative intraaortic
balloon pump (IABP) use during isolated CABG was
verified in the operative records.
STATISTICAL ANALYSIS. The primary outcome was the
need for reintubation during the postoperative hos-
pital stay. According to STS criteria, reintubation was
defined as patients reintubated within 30 post-
operative days during the hospital stay after the
initial extubation, including patients extubated in the
OR who required subsequent reintubation in the OR.
Secondary outcome measures included: reoperation
ROOM for bleeding, reoperation for any cause, total number
of grafts performed, total operative time, time from
skin closure to OR exit, need for prolonged

FIGURE Intensive care unit (ICU) vs operating room (OR) extubations over time.
90 JAMES ET AL Ann Thorac Surg
SAFETY OF OR EXTUBATION AFTER CABG 2024;117:87-95

TABLE 2 Intensive Care Unit vs Operating Room Extubation by Year and Case
extended care facility. The distributions of baseline
Type characteristics were checked using the Shapiro-Wilk
test for normalcy. Continuous variables were
Extubation Site 2017 2018 2019 2020 2021 2022
presented as mean
SD for normally distributed
Intensive care unit
data or median and interquartile range (IQR) for
OPCAB 8 (3.3) 1 (0.4) 1 (0.5) 0 (0.0) 0 (0.0) 0 (0.0)
nonnormally distributed data. Categoric data were
MIDCAB 2 (0.8) 2 (0.9) 2 (0.9) 2 (1.7) 0 (0.0) 0 (0.0)
CABG on CPB 231 (95.9) 220 (98.7) 212 (98.6) 115 (93.8) 47 (100.0) 48 (100.0) summarized using frequency and percentage. The
Operating room Student t test was used to compare normally
OPCAB 1 (6.3) 1 (6.7) 0 (0.0) 0 (0.0) 2 (1.3) 1 (0.4) distributed continuous variables between groups,
MIDCAB 8 (50.0) 11 (73.3) 9 (81.8) 9 (13.8) 9 (5.6) 11 (4.6) and the Mann-Whitney U test was used for
CABG on CPB 7 (43.8) 3 (20.0) 2 (18.2) 56 (86.2) 149 (93.1) 227 (95.0) nonnormally distributed continuous variables. The
significance of outcomes between groups was
Values are n (%). CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; MIDCAB, minimally
invasive direct coronary artery bypass; OPCAB, off-pump coronary artery bypass. measured using single-factor analysis of variance.
All tests were 2-sided, with an a level of 0.05
considered to indicate statistical significance.
ventilation, postoperative atrial fibrillation (POAF), Propensity score matching was used to adjust for
postoperative stroke or transient ischemic attack potential patient-related and operation-related
(TIA), postoperative renal failure, ICU hours, post- confounding variables. Patients were matched 1:1
operative hospital LOS, discharge disposition, 30-day without replacement k-nearest neighbor algorithm,
readmission rate, and 30-day mortality. Prolonged with a caliper of 0.10 and a CI of 0.95. Analysis of
ventilation was defined as greater than 24 hours of propensity-matched patients was conducted using
postoperative mechanical ventilator support.21 POAF XLStat Excel plug-in software (Microsoft). OR-
was defined as atrial fibrillation occurring after extubated patients and ICU-extubated patients were
surgery and that required treatment during the propensity matched on the basis of age, BMI, EF,
hospitalization, and postoperative renal failure was STS Mortality risk score, STS prolonged ventilation
defined as a new requirement for hemodialysis at score, CPB time, and aortic XC time. The Student t
the time of discharge. Discharge disposition was test and c2 test were used to compare the 2
dichotomized into 2 groups: home or other propensity-matched groups’ baseline continuous and
categoric variables, respectively.

TABLE 3 Baseline Characteristics Before Propensity Score Matching

RESULTS
Original Cohort

ICU Extubation OR Extubation

Baseline Characteristics n ¼ 891 n ¼ 506 P Value
Over the 6-year study period, 1397 patients underwent
Age, y 66 (59-72) 65 (58-71) .1197
nonemergency, isolated CABG: 891 (63.8%) were extu-
Racea .0032 bated in the ICU, and 506 (36.2%) were extubated in the
White 603 (67.3) 295 (58.3) OR. Propensity score matching was performed and
African American 62 (6.9) 42 (8.3) resulted in 414 matched pairs (Table 1). The incidence of
Other 231 (25.8) 169 (33.4) OR extubation increased over time, with a steep
Sex <.0001
inflection point in 2020 (Figure). Between years 1 and 3
Male 687 (77.1) 437 (86.4)
of the study period, 4.9% to 6.7% of patients were
Female 204 (22.9) 69 (13.6)
2 extubated in the OR. This increased to 35.7% of
BMI, kg/m 27.7 (24.5-31.3) 27.3 (24.8-30.8) .3275
STS risk score 0.9 (0.5-1.6) 0.8 (0.5-1.3) .0081 patients in year 4, 77.3% of patients in year 5, and
STS prolonged ventilation score 5.0 (3.4-8.4) 4.5 (3.1-6.9) .0003 83.3% of patients in year 6. Before 2020, OR
Diabetes 510 (57.2) 274 (54.2) .2635 extubation was limited to highly selected patients
Hypertension 793 (89.0) 455 (89.9) .5924 undergoing OPCAB or minimally invasive coronary
Dialysis 36 (4.0) 12 (2.4) .0998 artery bypass (Table 2).
Cerebrovascular disease 112 (12.6) 65 (12.8) .8816
EF % 60 (50-65) 60 (55-65) <.0001 UNMATCHED PATIENT CHARACTERISTICS. Baseline pa-
CPB, min 104 (85-123) 112 (94-130) <.0001
tient characteristics of the entire cohort before pro-
Cross-clamp, min 79 (62.0-95.8) 91.5 (73.3-107.0) <.0001
pensity score matching are presented in Table 3. In the
Preoperative or intraoperative IABP 80 (9.0) 11 (2.2) <.0001
unmatched cohort, there were no differences between
a
Patients can list multiple races, so the race category sum may be larger than the total number of patients in the 2 groups with respect to median age (66 [IQR, 59-
the sample. Values are median (interquartile range) or n (%). Boldface indicates significant P values. BMI, body
72] years vs 65 [IQR, 58-71] years; P ¼ .1197), BMI,
mass index; CPB, cardiopulmonary bypass; EF, ejection fraction; IABP, intraaortic balloon pump; STS, The
Society of Thoracic Surgeons. diabetes, hypertension, chronic kidney disease with
need for dialysis, or cerebrovascular disease. Female
Ann Thorac Surg JAMES ET AL 91
2024;117:87-95 SAFETY OF OR EXTUBATION AFTER CABG

TABLE 4 Baseline Characteristics After Propensity Score Matching

Propensity-matched Cohort

Baseline Characteristics Used in ICU Extubation OR Extubation

Propensity Score Matching N ¼ 414 N ¼ 414 SMD

Age, y 64 (58-71) 65 (58-71) (0.002)

BMI, kg/m2 28.1 (25.1-31.7) 27.4 (24.8-30.8) 0.003
STS risk score % 0.8 (0.5-1.3) 0.8 (0.5-1.3) 0.073
STS prolonged ventilation score 4.4 (3.0-6.6) 4.7 (3.3-7.1) 0.020
EF % 60 (55-65) 60 (55-65) (0.050)
CPB, min 110.5 (91.3-126.0) 110.0 (94.0-128.0) 0.013
Cross-clamp, min 89.0 (71.3-102.0) 90.0 (72.0-104.8) 0.025

ICU Extubation OR Extubation

Other Baseline Characteristics n ¼ 414 n ¼ 414 P Value

Racea .0520
White 272 (64.9) 235 (56.8)
African American 30 (7.2) 34 (8.2)
Other 117 (27.9) 145 (35.0)
Sex .087
Male 339 (81.9) 357 (86.2)
Female 75 (18.1) 57 (13.8)
Diabetes 238 (57.5) 238 (57.5) 1.0000
Hypertension 374 (90.3) 374 (90.3) 1.0000
Dialysis 14 (3.4) 10 (2.4) .4073
Cerebrovascular disease 46 (11.1) 56 (13.5) .2903
Preoperative or intraoperative IABP 20 (4.8) 10 (2.4) .0630

a
Patients can list multiple races, so the race category sum may be larger than the total number of patients in the sample. Values are median (interquartile range) or n (%).
BMI, body mass index; CPB, cardiopulmonary bypass; EF, ejection fraction; IABP, intraaortic balloon pump; ICU, intensive care unit; OR, operating room; SMD,
standardized mean difference; STS, The Society of Thoracic Surgeons.

patients and White patients were more likely to be were more likely to require preoperative or
extubated in the ICU compared with male patients and intraoperative IABP (9.0% vs 2.2%; P < .0001), whereas
patients who were not White. ICU-extubated patients OR-extubated patients had higher EF (60% [IQR,

TABLE 5 Postoperative Outcomes Before and After Propensity Score Matching

Original Cohort Propensity-matched Cohort

ICU Extubation OR Extubation ICU Extubation OR Extubation

Outcome n ¼ 891 n ¼ 506 P Value n ¼ 414 n ¼ 414 P Value

Primary outcome
Need for reintubation 20 (2.2) 8 (1.6) .3953 7 (1.7) 7 (1.7) 1.0000
Secondary outcomes
ICU hours 21 (16-39) 14 (12-19) <.0001 20 (16-28) 14 (12-19) <.0001
Postoperative LOS, d 5 (4-7) 3 (2-4) <.0001 5 (4-6) 3 (2-4) <.0001
Stroke or TIA 3 (0.3) 3 (0.6) .4819 2 (0.5) 2 (0.5) 1.0000
Discharge to home 754 (84.6) 492 (97.2) <.0001 372 (89.9) 403 (97.3) <.0001
Postoperative atrial fibrillation 171 (19.2) 27 (5.3) <.0001 62 (15.0) 21 (5.1) <.0001
Postoperative kidney injury 8 (0.9) 1 (0.2) .1160 2 (0.5) 1 (0.2) .5635
30-day readmission 44 (4.9) 12 (2.4) .0187 17 (4.1) 7 (1.7) .0384
30-day mortality 8 (0.9) 1 (0.2) .1160 3 (0.7) 1 (0.2) .3167
Reoperation for bleeding 10 (1.1) 7 (1.4) .6691 3 (0.7) 7 (1.7) .2036
Reoperation for any cause 28 (3.1) 8 (1.6) .0768 9 (2.2) 8 (1.9) .8067
Prolonged ventilation 52 (5.8) 5 (1.0) <.0001 15 (3.6) 4 (1.0) .0106
Total grafts 3.3 ± 1.0 3.4 ± 1.3 .0123 3.6 ± 0.9 3.7 ± 1.0 .0915
Total OR time, min 376 (331-420) 388 (343-430) .0027 390 (342-433) 394 (354-431) .3202
Skin close to OR end, min 16 (12-22) 20 (14-25) <.0001 16 (12-23) 20 (15-26) <.0001

Values are n (%), median (interquartile range), or mean ± SD. Boldface indicates significant P values. ICU, intensive care unit; LOS, length of stay; OR, operating room; TIA,
transient ischemic attack.
92 JAMES ET AL
SAFETY OF OR EXTUBATION AFTER CABG
55%-65%] vs 60% [IQR, 50%-65%]; P < .0001), lower STS
mortality risk scores (0.8% [IQR, 0.5%-1.3%] vs 0.9%
[IQR, 0.5%-1.6%]; P ¼ .0081], lower STS prolonged
ventilation scores (4.5% [IQR, 3.1%-6.9%] vs 5.0% [IQR,
3.4%-8.4%]); longer CPB times (112 [IQR, 94-130]
minutes vs 104 [IQR, 85-123] minutes; P < .0001), and
longer XC times (92 [IQR, 73-107] minutes vs 79 [IQR,
62-96] minutes; P < .0001).
PROPENSITY-MATCHED PATIENT CHARACTERISTICS.
OR-extubated patients and ICU-extubated patients
were propensity score matched on the basis of age, BMI,
EF, STS mortality risk score, STS prolonged ventilation
score, CPB time, and aortic XC time, resulting in 414
matched pairs (Table 4). Patients were well matched,
with all baseline covariates having a standardized mean
difference of less than 10%. In the propensity-matched
cohort, there were no differences between OR-extubated
patients and ICU-extubated patients with respect to sex,
race, the incidence of preoperative or intraoperative
IABP, or other major comorbidities.
POSTOPERATIVE OUTCOMES. Postoperative outcomes
are presented in Table 5. In the unmatched cohort,
there was no difference between OR-extubated and
ICU-extubated patients in the incidence of reintubation,
reoperation for bleeding, reoperation for any cause,
postoperative stroke/TIA, postoperative renal failure, or
30-day mortality. Compared with ICU-extubated
patients, OR-extubated patients had a longer total
operative time (388 [IQR, 343-430] minutes vs 376 [IQR,
331-420] minutes; P ¼ .0027) and skin closure to OR
exit time (20 [IQR, 14-25] minutes vs 16 [IQR, 12-22]
minutes; P < .0001), but they had more total grafts
performed (3.4
1.3 vs 3.3
1.0; P ¼ .0123), fewer ICU
hours (14 [IQR, 12-19] hours vs 21 [IQR, 16-39] hours;
P < .0001), less prolonged intubation (1.0% vs 5.8%;
P < .0001), shorter postoperative hospital LOS (3 [IQR,
2-4] days vs 5 [IQR, 4-7] days; P < .0001), and a lower
incidence of POAF (5.3% vs 19.2%; P < .0001).
Additionally, OR-extubated patients were more likely
to be discharged directly to home, (97.2% vs 84.6%;
P < .0001), and they had a lower 30-day readmission
rate (2.4% vs 4.9%; P ¼ .0187).
In the propensity-matched cohort, there were no
differences between OR-extubated and ICU-extubated
patients in the incidence of reintubation (1.7% vs 1.7%;
P ¼ 1.00), reoperation for bleeding (1.7% vs 0.7%; P ¼
.2036), reoperation for any cause (1.9% vs 2.2%; P ¼
.8067), number of total grafts performed (3.7
1.0 vs
3.6
0.9; P ¼ .0915), total operative time (394 [IQR, 354-
431] minutes vs 390 [IQR, 342-433] minutes; P ¼ .3202),
postoperative stroke or TIA (0.5% vs 0.5%; P ¼ 1.00),
postoperative renal failure (0.2% vs 0.5%; P ¼ .5635), or
30-day mortality (0.2% vs 0.7%; P ¼ .3167). Although
ICU-extubated patients had a slightly shorter skin
Ann Thorac Surg
2024;117:87-95
closure to OR exit time (16 [IQR, 12-23] minutes vs 20
[IQR, 15-26] minutes; P < .0001), they also had a higher
incidence of prolonged ventilation (3.6% vs 1.0%; P ¼
.0106), a higher incidence of POAF (15.0% vs 5.1%; P <
.0001), more ICU hours (20 [IQR, 16-28] hours vs 14 [IQR,
12-19] hours; P < .0001), and longer postoperative hos-
pital LOS (5 [IQR, 4-6] days vs 3 [IQR, 2-4] days; P <
.0001). Finally, compared with OR-extubated patients,
ICU-extubated patients were less likely to be discharged
directly to home vs to an extended care facility (89.9%
vs 97.3%; P < .0001), and they had a higher 30-day
readmission rate (4.1% vs 1.7%; P ¼ .0384).
COMMENT
This study compared perioperative outcomes after OR
extubation and ICU extubation in 1397 patients who
underwent nonemergency, isolated CABG over a 6-year
period. During the first 3 years of the study, fast-track
ICU extubation was the primary approach used. In
2020, we began to implement routine OR extubation as a
default strategy for all patients undergoing nonemer-
gency, isolated CABG. By the last year of the study, most
patients were extubated in the OR (83.3% in 2022).
In this propensity-matched analysis, there were no
differences between OR extubation and ICU extubation
in the incidence of reintubation, reoperation for
bleeding, reoperation for any cause, postoperative renal
failure, postoperative stroke or TIA, or 30-day mortality.
These findings demonstrate the safety of this strategy
because OR extubation was not associated with any in-
crease in perioperative morbidity or mortality. There
was no difference in the total operative time between
ICU and OR extubation, and OR-extubated patients had
a lower incidence of prolonged ventilation, fewer ICU
hours, and shorter postoperative hospital LOS. Although
a formal cost analysis was not performed, these data
suggest that OR extubation is almost certainly a cost-
effective strategy.
For many of the differences in postoperative out-
comes observed, it is difficult to determine the rela-
tive impact of OR extubation vs other management
strategies or protocols. It is likely that OR extubation
may have resulted in at least some of the differences
observed in ICU hours and postoperative hospital
LOS. Our postoperative care maps use progressive
trigger points for transitions in levels of care, which
include mobilizing patients from out of bed into a
chair within 3 hours of ICU arrival, ambulation within
3 to 6 hours, and removal of lines and chest tubes.
After serial benchmarks are met, the patient can be
transitioned from an ICU setting to an intermediate
level of care. Most OR-extubated patients meet the
criteria for initial transition of care on postoperative
day 0 and subsequently progress early on
Ann Thorac Surg
2024;117:87-95
postoperative day 1. It is possible that these earlier
care transitions, with earlier ambulation and physical
therapy, contributed to the decreased ICU hours and
postoperative hospital LOS.
For other outcome differences in OR-extubated pa-
tients, such as the lower incidence of POAF, the higher
direct-to-home discharge rate, and lower 30-day read-
mission rate, the impact of OR extubation is less certain.
Previous studies have demonstrated that OR extubation
after OPCAB reduced the incidence of POAF, indepen-
dent of underlying comorbidities.22 However, we have
simultaneous protocols in place for placement of left
atrial appendage clips and prophylactic amiodarone for
certain patients, which likely also contributed to the
decreased incidence of POAF. Similarly, surgeon-
specific patient management decisions may have
contributed to the differences in direct-to-home
discharge and 30-day readmission rate.
This study has several limitations. It was not an
intention-to-treat analysis, and thus crossover from
planned OR extubation to extubation in the ICU was
allowed if events occurred that were thought to be a
contraindication to extubation at the conclusion of the
procedure. We have no data to determine how often
such crossover may have occurred, but this selection
process could have potentially biased the results and
would not have been captured by propensity matching.
Similarly, propensity matching cannot account for other
unobserved variables that could have influenced
REFERENCES
1. Reyes A, Vega G, Blancas R, et al. Early vs conventional extubation after
cardiac surgery with cardiopulmonary bypass. Chest. 1997;112:193-201.
2. Cheng DCH, Karski J, Peniston C, et al. Morbidity outcome in early
versus conventional tracheal extubation after coronary artery bypass
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3. Cheng DCH, Karski J, Peniston C, et al. Early tracheal extubation after
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use: a prospective, randomized, controlled trial. Anesthesiology. 1996;85:
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4. Cheng DCH, Peragallo RA. Randomized assessment of resource use in
fast-track cardiac surgery 1-year after hospital discharge. Anesthesiology.
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5. Guller U, Anstrom KJ, Holman WL, Allman RM, Sansom M, Peterson ED.
Outcomes of early extubation after bypass surgery in the elderly. Ann
Thorac Surg. 2004;77:781-788.
6. Svircevic V, Nierich AP, Moons KGM, Brandon Bravo Bruinsma GJ,
Kalkman CJ, Van Dijk D. Fast-track anesthesia and cardiac surgery: a
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7. Myles PS, Djaiani G, Cheng DCH. A systematic review of the safety and
effectiveness of fast-track cardiac anesthesia. Anesthesiology. 2003;99:
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8. Wong WT, Lai VK, Chee YE, Lee A. Fast-track cardiac care for adult
cardiac surgical patients. Cochrane Database Syst Rev. 2016;9:CD003587.
https://doi.org/10.1002/14651858.CD003587.pub3
JAMES ET AL 93
SAFETY OF OR EXTUBATION AFTER CABG
decisions related to OR vs ICU extubation strategies.
Moreover, the STS mortality risk score for the patients in
this study was quite low (0.8%). This finding reflects the
low risk profile of the patient population studied
because patients requiring certain forms of mechanical
circulatory support (eg, extracorporeal membrane
oxygenation or Impella) or emergency procedures were
excluded. Therefore, these results may not be transfer-
able to other higher-risk patient populations.
Despite these limitations, these results provide
convincing evidence that routine OR extubation after
nonemergency, isolated CABG is feasible and safe and
can be used as a default strategy across a broad spectrum
of patients without an increased risk of reintubation,
reoperation for bleeding, or other perioperative
morbidity or mortality, with minimal impact on total
operative time. It is possible that OR extubation may
affect ICU hours and postoperative hospital LOS, and
these data suggest that it is cost-effective. These find-
ings support wider adoption of routine OR extubation
for nonemergency, isolated CABG.
FUNDING SOURCES
The authors have no funding sources to disclose.
DISCLOSURES
Eugene A. Grossi reports a relationship with Medtronic that includes:
consulting or advisory. Aubrey C. Galloway reports a relationship with
Medtronic that includes: consulting or advisory. All other authors declare
that they have no conflicts of interest.
9. Fitch ZW, Debesa O, Ohkuma R, et al. A protocol-driven approach to
early extubation after heart surgery. J Thorac Cardiovasc Surg. 2014;147:
1344-1350.
10. Trouillet JL, Combes A, Vaissier E, et al. Prolonged mechanical venti-
lation after cardiac surgery: outcome and predictors. J Thorac Cardiovasc
Surg. 2009;138:948-953.
11. Grant MC, Isada T, Ruzankin P, et al. Results from an enhanced re-
covery program for cardiac surgery. J Thorac Cardiovasc Surg. 2020;159:
1393-1402.e7.
12. Shahian DM, Jacobs JP, Badhwar V, et al. The Society of Thoracic
Surgeons 2018 adult cardiac surgery risk models: part 1—background,
design considerations, and model development. Ann Thorac Surg.
2018;105:1411-1418.
13. STS quality webinar series: prolonged ventilation. The Society of
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14. Straka Z, Brucek P, Vanek T, Votava J, Widimsky P. Routine immediate
extubation for off-pump coronary artery bypass grafting without thoracic
epidural analgesia. Ann Thorac Surg. 2002;74:1544-1547.
15. Horswell JL, Herbert MA, Prince SL, Mack MJ. Routine immediate
extubation after off-pump coronary artery bypass surgery: 514 consecutive
patients. J Cardiothorac Vasc Anesth. 2005;19:282-287.
94 JAMES ET AL
SAFETY OF OR EXTUBATION AFTER CABG
16. Nagre AS, Jambures NP. Comparison of immediate extubation versus
ultrafast tracking strategy in the management of off-pump coronary artery
bypass surgery. Ann Card Anaesth. 2018;21:129-133.
17. Chamchad D, Horrow JC, Nakhamchik L, et al. The impact of immediate
extubation in the operating room after cardiac surgery on intensive care and
hospital lengths of stay. J Cardiothorac Vasc Anesth. 2010;24:780-784.
18. Badhwar V, Esper S, Brooks M, et al. Extubating in the operating room
after adult cardiac surgery safely improves outcomes and lowers costs.
J Thorac Cardiovasc Surg. 2014;148:3101-3109.e1.
19. Totonchi Z, Azarfarin R, Jafari L, et al. Feasibility of on-table extubation
after cardiac surgery with cardiopulmonary bypass: a randomized clinical
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ª 2024 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
Extubation After Cardiac Surgery: It’s
Not the Destination, It’s the Journey
INVITED COMMENTARY:
In this issue of The Annals of Thoracic Surgery, James
and colleagues1 have reported on the results of a single-
center, propensity-matched (N ¼ 414 pairs), observa-
tional study investigating the association between
intraoperative extubation and postoperative outcomes
after cardiac surgery. Along with similarities in reintu-
bation, reoperation for bleeding, operative time, stroke,
renal failure, and mortality, patients extubated in the
operating room (OR) experienced shorter intensive care
and hospital length of stay, were more likely to be dis-
charged to home, and had lower rates of readmission
compared with conventional postoperative extubation.
There are limitations to the study, which include the
caveat that propensity matching can only control for
specific confounders and not bias on the part of the care
team, but the results are nonetheless compelling.
In fact, this study provides another datapoint to the
growing body of literature in support of earlier (and
earlier) extubation after cardiac surgery, including a
handful of recent examples that assess both the safety
and efficacy of intraoperative extubation.2-5 At first
glance, one would not be faulted for concluding that the
intervention described by James and colleagues1 was
simply the removal of an endotracheal tube, but a
closer reading suggests that the real impact of their
work was the myriad of decisions that preceded this
recovery milestone. The authors select for
homogenous cohort (ie, isolated coronary artery bypass
grafting) and exclude high-risk patients (ie, significant
vasopressors, considerable bleeding, or mechanical
support) from their analysis, essentially reinforcing
lessons learned from prior work that established pre-
dictors of successful OR extubation.2 The group
embraced a balanced intraoperative anesthetic,
Ann Thorac Surg
2024;117:87-95
20. Hawkins AD, Strobel RJ, Mehaffey JH, et al. Operating room versus
intensive care unit extubation within 6 hours after on-pump cardiac
surgery: early results and hospital costs. Semin Thorac Cardiovasc Surg.
Published online November 29, 2022. https://doi.org/10.1053/j.semtcvs.
2022.09.013
21. Jacobs JP, He X, O’Brien SM, et al. Variation in ventilation time after
coronary artery bypass grafting: an analysis from The Society of Thoracic
Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2013;96:757-
762.
22. Edgerton JR, Herbert MA, Prince SL, et al. Reduced atrial fibrillation in
patients immediately extubated after off-pump coronary artery bypass
grafting. Ann Thorac Surg. 2006;81:2121-2127.
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2023.09.047
targeted administration of opioids, and shorter-acting
sedatives to optimize patients for extubation at the
end of the procedure. Careful selection coupled with a
thoughtful anesthetic can subtly, but importantly, shift
the discussion away from determining who might be
suitable and instead identified who is not suitable for OR
extubation. It is also clear that any potential benefits
associated with intraoperative extubation are the result
of a notable initial learning curve. An inflexion point was
found several years into the study upon which the ma-
jority of patients were routinely extubated in the OR.
Recent data presented at The Society of Thoracic Sur-
geon’s Annual Meeting suggested that only centers with
greater experience (defined as >40% of cases extubated
in the OR) may avoid potential complications associated
with the practice.3
What remains unclear is whether intraoperative
extubation conveys an advantage over the immediate
(<1 hour) or even early (<6 hours) postoperative alter-
native. Whereas prior studies comparing the timepoints
found OR extubation to be cost-effective, there were
conflicting results regarding safety.4,5 Others have
published their experience on the use of goal-directed
anesthetic protocols and concluded that although pa-
tients were extubated earlier, it was more likely
compliance with protocol elements that ultimately
translated into shorter length of hospital stay.6 It is in
this context that perhaps it is time to emphasize
“readiness for extubation” rather than extubation
itself. After all, for both our patients and our service-
a lines, the journey is just as important as the
destination.
FUNDING SOURCES
The author has no funding sources to disclose.
DISCLOSURES
The author has no conflicts of interest to disclose.