Early extubation can be associated with medical and financial benefits. Early extubation helps avoid complications associated with prolonged intubation such as atelectasis, diaphragmatic atrophy, retained pulmonary secretions, and pneumonia. In addition, positive pressure ventilation can have adverse hemodynamic effects due to decreased venous return, and sedatives required to maintain patient comfort while intubated can exacerbate perioperative hypotension and increase risk of delirium. Early extubation reduces these risks and can also decrease cost by lowering staffing requirements and duration of ICU stay, and helping ensure bed availability for future cardiac surgery patients.

However, early extubation is not appropriate for all patients. Post-extubation respiratory failure leads to hypoxemia, hypercarbia, and myocardial or neurologic ischemia and injury. Monetary savings realized from early extubation can be rapidly lost by one adverse event. Intraoperative and postoperative care must be coordinated to optimize patients for early cessation of invasive mechanical ventilation. Goal-directed fluid management, lung-protective ventilation, and multimodal analgesic strategies can contribute to this. Careful patient selection, with attention to underlying cardiopulmonary comorbidity and surgical complexity, is essential.

References

• Baxter R, Squiers J, Conner W, et al. Enhanced recovery after surgery: a narrative review of its application in cardiac surgery. Ann Thorac Surg. 2020;109:1937-1944.
• McCarthy C, Fletcher N. Early extubation in enhanced recovery from cardiac surgery. Crit Care Clin. 2020;36:663-674.