The safety of immediate extubation, and factors associated with delayed extubation, in cardiac surgical patients receiving fast-track cardiac anesthesia: An integrative review

BACKGROUND: Early extubation (EE), within 8 h of cardiac surgery, is associated with improved resource utilization. Studies have demonstrated that for patients receiving low-dose, fast-track opioid cardiac anesthesia (FTCA) protocols, EE is as safe as conventional care. To date, it is unclear when the earliest timepoints for safe extubation might be. Additionally, some authors pointed out that certain patients receiving FTCA protocols frequently experience delays during extubation attempts. Understanding the factors associated with delayed extubation is crucial for perioperative planning and resource management. This review seeks to 1) determine whether immediate extubation (IE) in the operating room is as safe as EE and 2) identify factors associated with delayed extubation. METHODS: MEDLINE, Cochrane Library, EMBASE and CINAHL (up to March 2022) were searched. Studies pertaining to FTCA, IE, EE or factors associated with delayed extubation were included. All authors extracted, appraised and synthesized data. The primary outcome measures were treatment results and factors associated with delayed extubation. RESULTS: Six studies investigated treatment outcomes associated with FTCA and IE. One randomized controlled trial reported that outcomes associated with IE were comparable to those with EE. Five observational studies reported incidence for 19 treatment outcomes associated with IE, but no comparisons were made to EE. Six observational studies assessed pre- and intraoperative factors associated with delayed extubation in FTCA patients. In at least one study, 37 factors were investigated and 22 were identified. The most frequently reported factors were pre-existing cardiac insufficiency or renal disease, time on pump and cross-clamp time. Obesity and stroke were investigated but were not associated with delayed extubation. No study examined the influence of race, ethnicity or gender on outcomes. DISCUSSION AND CONCLUSION: Evidence pertaining to treatment outcomes associated with FTCA and IE is weak. Observational studies cannot determine causation. Large multicentre randomized control trials are required to determine the safety of IE. Although numerous factors have been associated with delayed extubation, several studies do not describe how or which factors were selected for examination. Therefore, certain factors may have yet to be evaluated. Future studies should comprehensively define all factors under investigation.