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Department of Anesthesia and Pain Management, The Royal Melbourne Hospital, and Department of Pharmacology, The Unviersity of Melbourne Department of Cardiac Surgery, The Royal Melbourne Hospital, and Department of Surgery, The University of Melbourne
To the Editor:
We commend Montes and colleagues (1) for their study investigating immediate extubation after coronary artery bypass surgery. We are not entirely surprised that they had a more frequent than expected reintubation rate. The key to successful immediate or very early extubation is to have the patient normothermic, hemodynamically stable, awake, and to provide adequate nonopioid analgesia (2). Two aspects of their technique may have contributed to reintubation. The mean minimum temperature in both groups was below 32°C, which could lead to early hypothermia despite "full rewarming" during cardiopulmonary bypass. They do not mention whether forced air warmers were used to maintain normothermia after the termination of cardiopulmonary bypass. Hypothermia could lead to restlessness and shivering. Secondly, they used opioid-based analgesia, which could contribute to respiratory depression. We agree that cost savings are unlikely with immediate versus very early extubation unless there is an additional staff requirement to provide ventilatory support. Although we have performed immediate extubation without reintubation, it is a technique that demands exact fulfilment of the conditions mentioned above, and is made simpler by the use of epidural anesthesia. Commencing spontaneous ventilation in the operating theater and performing tracheal extubation in the intensive care unit can achieve most goals of immediate extubation. This is a simpler and perhaps safer approach for surgical units aiming for very early extubation.
References
Department of Anesthesiology, Fundación Cardio-Infantil, Universidad del Rosario, Bogotá, Colombia
In Response:
We highly appreciate the interesting comments made to our article (1). This also gives us an opportunity to clarify some aspects of our study. We do not routinely use forced air warmers after termination of cardiopulmonary bypass and although the hypothermia could be a reason for reintubation, we believe that this was not the case because the temperature was monitored closely during the study. We can not quantify the probable contribution of opioid-based analgesia to the reintubation rate, but we believe the dose used (fentanyl 20–30 µg/h) was too small to be responsible. The utilization of other nonopioid drugs or techniques for analgesia and sedation could be a good alternative in decreasing the rate of reintubation (2); we have no experience using epidural analgesia in patients who will subsequently undergo full or partial systemic heparinization and in fact, a large number of our patients come to the operating room receiving heparin drip.
Although we cannot prove any benefit of immediate versus very early extubation, we were also unable to demonstrate any significant problems with the extubation in the operating room because there was not a statistically significant increase in adverse events. Our article implies that reintubation does not have a deleterious effect in the general status of the patient, and it is not associated with an unfavorable outcome should expert personnel perform such a procedure.
References
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