The Feasibility of Routine Early Extubation after Cardiac Surgery Protocol Generalized to a Nascent, Resource-limited Setup

Objectives: The ultra-fast track protocol using a combination of anesthesia pre-habilitation and intra-operative goal-directed management is increasingly making the extubation of cardiac surgery patients in the operation room feasible. However, the on-table extubation of these patients requires critical evaluation and efforts of the multi-disciplinary experienced team and is practiced only in a few established centers. With this study, the authors aim to evaluate the outcomes of their customized ultra-fast track protocol on the feasibility of on-table and early extubation and its implications on post-operative outcomes in their newly established cardiac surgery setup. Material and Methods: This is a retrospective observational study, performed in the operation theater and postoperative intensive care unit (ICU) under a tertiary care government teaching hospital between April 2022 and October 2023. Patients aged 1–70 years undergoing elective cardiac surgery under cardiopulmonary bypass (CPB) with a customized ultra-fast track anesthesia protocol were included in the study. This is the retrospective chart review of case records, anesthesia, perfusionist, and surgical records. The anesthesia was established using standardized and customized institutional protocols. After completion of surgery, the patients were extubated either in the operation room or in ICU, depending upon the suitability criteria. Results: During the study period, of the 96 patients, 30 were included under the ultra-fast track protocol. Out of 30, seven (23.33%) could be extubated on table and five (16.67%) within 6 h of surgery. The post-bypass lactate (1.90 vs. 3.00; P = 0.04) was the major determining factor for the feasibility of on-table extubation. None of the patients extubated on-table were re-intubated. There was no difference in the post-operative surgical, cardiac, and pulmonary outcomes of the three subsets of the patients. The patients extubated early in ICU were younger and had shorter bypass (CPB) and aortic cross-clamp (AXC) times with low vasopressor inotropic scores (VISs) with shorter ICU stay (1 day vs. 3.50 days, P = 0.002) and hospital stay (7 days vs. 11.50 days, P = 0.002). The post-operative opioid consumption was lesser (180 mcg fentanyl vs. 400 mcg, P = 0.040). The patient age <46.50 years CPB time 147.50 min AXC time <108 min and VIS <6 could predict early extubation. Conclusion: The on-table extubation appears to be safe in patients undergoing ultra-fast track anesthesia with post-bypass lactate levels being the significant determinant. Young patients with short CPB and AXC times and low VIS scores have greater probability of early extubation, with shorter ICU and hospital stay time.