Massachusetts Chapter of the American College of Surgeons

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Evaluation of an Extubation Protocol Incorporating Neostigmine on Ventilation Time After Cardiac Surgery
Dominic Recco, MD1, Sumedh Kaul, MS2, Michelle Doherty, MSN, RN1, Dawn McDougal, APN1, Kamal R. Khabbaz, MD1
1Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Department of Surgery, FIRST Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Background: Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. The effect of neuromuscular blockade reversal (NMBR) on cardiac surgery outcomes, specifically postoperative ventilation time, is uncertain.
Methods: A multidisciplinary extubation protocol comprised of guidelines outlining ventilator weaning and NMBR administration was implemented on 2/29/2016. Databases were queried for patients who underwent cardiac surgery from 2/29/2015 to 2/29/2017. The associations of baseline characteristics with postoperative ventilation time (primary end point) and respiratory/adverse complications (secondary outcomes) were evaluated using negative binomial regression models.
Results: 1843 patients were identified, 957(52%) of whom underwent cardiac surgery on or after 2/29/2016. Adjusting for covariates, implementation of a multidisciplinary extubation protocol was associated with a 18% decrease in postoperative ventilation time (CI 0.72-0.94; p<0.01), 26% increase in patients extubated <=6 hours (CI 0.97-1.65; p=0.09) and 13% shorter ICU LOS (CI 0.79-0.97; p<0.01). When accounting for procedure type, patients undergoing isolated-CABG or -valve procedures on or after 2/29/16 had decreased extubation times (IRR 0.82, p<0.01 and IRR 0.80, p=0.02; respectively), compared to patients post isolated-CABG or -valve prior to 2/29/2016, respectively. The protocol did not have statistically significant association with hospital LOS (p=0.57) or readmission (p=0.33) and differences in the occurrence of adverse outcomes (e.g., mortality, pneumonia, reintubation, and renal failure) between the pre- and post-protocol groups were clinically insignificant.
Conclusion: Application of a multidisciplinary exubation protocol incorporating NMBR can decrease postoperative ventilation time and facilitate more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.


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