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Original Articles ORIGINAL ARTICLES Predictors of Prolonged Postoperative Endotracheal Intubation in Patients Undergoing Thoracotomy for Lung Resection Jacek B. Cywinski, MD,* Meng Xu, MS,† Daniel I. Sessler, MD,‡ David Mason, MD,§ and Colleen Gorman Koch, MD, MS¶ Objective: The aim of this study was to identify predictors sion, higher preoperative serum creatinine level, absence of a of delayed endotracheal extubation defined as the need for thoracic epidural catheter, more extensive surgical resection, postoperative ventilatory support after open thoracotomy and lower preoperative FEV1 were associated with an in- for lung resection. creased risk of delayed extubation after lung resection. Design: An observational cohort investigation. Conclusion: Most predictors of delayed postoperative extu- Setting: A tertiary referral center. bation (ie, red blood cell transfusion, higher preoperative se- Participants: The study population consisted of 2,068 pa- rum creatinine, lower preoperative FEV1, and more extensive tients who had open thoracotomy for pneumonectomy, lo- lung resection) are difficult to modify in the perioperative pe- bectomy, or segmental lung resection between January riod and probably represent greater severity of underlying lung disease and more advanced comorbid conditions. However, 1996 and December 2005. thoracic epidural anesthesia and analgesia is a modifiable fac- Interventions: Not applicable. tor that was associated with reduced odds for postoperative Measurements and Main Results: Preoperative and intra- ventilatory support. Thus, the use of epidural analgesia may operative variables were collected concurrently with the pa- reduce the need for post-thoracotomy mechanical ventilation. tient’s care. Risk factors were identified using logistic regres- © 2009 Elsevier Inc. All rights reserved. sion with stepwise variable selection procedure on 1,000 bootstrap resamples, and a bagging algorithm was used to KEY WORDS: anesthesia, thoracotomy, postoperative me- summarize the results. Intraoperative red blood cell transfu- chanical ventilation, lung resection, extubation ELAYED POSTOPERATIVE EXTUBATION prolongs demographic variables, comorbid conditions, laboratory values, and Dthe duration of recovery, increases cost, and may augment operative and outcome variables were collected concurrently with postoperative morbidity.1 Early extubation (defined as extubation patient care by individuals trained in database management in the in the operating room [OR]) decreases resource utilization, im- Department of Cardiothoracic Anesthesiology. Institutional review proves patients’ comfort, reduces morbidity related to mechanical board approval was obtained to perform analyses from the department registry. Perioperative anesthetic care was not dictated by any specific ventilation, and possibly allows for early ambulation and rehabil- protocol. Decisions about patient management were left to the discre- 2,3 itation. After thoracic procedures and especially after lung re- tion of the attending anesthesiologist with the goal to provide optimal section, an additional benefit of limiting positive-pressure mechan- surgical conditions and the ability to extubate at the end of the surgical ical ventilation may include reducing pressure stress on the lung procedure. However, it has been the authors’ practice to initiate epi- tissue suture line, potentially decreasing postoperative air leak.4-6 dural catheters during the surgical procedure to achieve adequate Identifying patients at risk for delayed extubation may allow analgesia at the time of emergence from general anesthesia. clinicians to institute appropriate interventions perioperatively, Descriptive statistics were calculated for all key predictors and demo- which might in turn decrease the duration of postoperative graphic variables. Continuous variables were described with median and ventilatory support and allow for more efficient resource allo- 25th and 75th percentiles, with p values for tests of differences between the cation. The authors’ objective was to identify preoperative 2 groups (extubated in the OR v not extubated in the OR). Categoric variables were described with frequencies and percents, with p values for variables associated with delayed postoperative extubation af- tests of differences between groups. Univariate analysis was performed ter thoracotomy for lung resection. with a chi-square test or Fisher exact test and Wilcoxon rank sum test where appropriate. Categoric outcomes in the two groups were compared METHODS with a chi-square test or Fisher exact test as appropriate. The patient population consisted of 2,068 patients who had open Multivariable logistic regression was used to determine variables that lung resection surgery (pneumonectomy, lobectomy, or segmental lung were associated with postoperative ventilatory support. Risk factors were resection) between January 1996 and December 2005. Preoperative selected by using logistic regression with a stepwise variable selection procedure on 1,000 bootstrap resamples. A bagging algorithm was used to summarize the results. Entry criterion and stay criterion for the stepwise From the Departments of *General Anesthesiology, †Quantitative selection processes were 0.07 and 0.05, respectively. The final logistic Health Sciences, ‡Outcomes Research, §Thoracic and Cardiovascular Sur- regression models for the outcomes were built by using risk factors that gery, and ¶Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH. appeared in 50% of all models from the bootstrap resamples. Address reprint requests to Jacek B. Cywinski, MD, Department of General Anesthesia/E31, Cleveland Clinic, 9500 Euclid Avenue, Cleve- RESULTS land, OH 44195. E-mail: [email protected] © 2009 Elsevier Inc. All rights reserved. Table 1 presents a comparison of patients who were extubated 1053-0770/09/2306-0002$36.00/0 in the OR versus those who arrived to a recovery area intubated, doi:10.1053/j.jvca.2009.03.022 based on categoric preoperative and intraoperative variables. Pa- 766 Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 6 (December), 2009: pp 766-769 PROLONGED POSTOPERATIVE ENDOTRACHEAL INTUBATION 767 Table 1. Comparison of Patients Who Were Extubated in the OR Versus Those Who Arrived to a Recovery Area Intubated Based on Categoric Preoperative and Intraoperative Variables Arrived Extubated Arrived Intubated Factor Level Total N (%) N (%) p Value* Male sex 0.58 No 912 788 44.3 124 42.6 Yes 1,156 989 55.7 167 57.4 History of COPD or asthma 0.17 No 1,566 1,355 76.3 211 72.5 Yes 502 422 23.8 80 27.5 History of diabetes 0.11 No 1,820 1,572 88.5 248 85.2 Yes 248 205 11.5 43 14.8 History of stroke 0.023 No 1,978 1,707 96.1 271 93.1 Yes 90 70 3.9 20 6.9 History of end-stage renal disease requiring dialysis 0.99† No 2,061 1,771 99.7 290 99.7 Yes 7 6 0.34 1 0.34 History of smoking 0.62 No 493 427 24.0 66 22.7 Yes 1,575 1,350 76.0 225 77.3 Intraoperative RBC transfusion Ͻ0.001 No 1,857 1,643 92.5 214 73.5 Yes 211 134 7.5 77 26.5 Intraoperative placement of intercostal nerve block 0.46† No 2,064 1,774 99.8 290 99.7 Yes 4 3 0.17 1 0.34 Use of thoracic epidural analgesia Ͻ0.001 No 345 256 14.4 89 30.6 Yes 1,723 1,521 85.6 202 69.4 Use of lumbar epidural analgesia Ͻ0.001 No 1,892 1,637 92.1 255 87.6 Yes 176 140 7.9 36 12.4 Procedure Ͻ0.001 SLR 241 225 12.7 16 5.5 LOL 1,501 1,298 73.0 203 69.8 CP 326 254 14.3 72 24.7 Reintubated Ͻ0.001 No 1,882 1,649 92.8 233 80.1 Yes 186 128 7.2 58 19.9 Abbreviations: LOL, lobectomy of lung; SLR, segmental lung resection; CP, complete pneumonectomy; COPD, chronic obstructive pulmonary disease; RBC, red blood cell. *Chi-square test unless noted. †Fisher exact test. tients who were not extubated in the OR had more intraoperative The final multivariate logistic regression identified the follow- red blood cell (RBC) transfusions, a history of preoperative stroke, ing predictors of postoperative prolonged intubation: intraopera- lower use of thoracic epidural analgesia (TEA), and a higher rate tive RBC transfusion (odds ratio ϭ 2.68 [1.92, 3.74], p Ͻ 0.001), of intraoperative use of lumbar epidural analgesia. A comparison absence of TEA catheter (odds ratio ϭ 2.27 [1.72, 3.03], p Ͻ 0.001), of continuous variables is summarized in Table 2. Patients who elevated preoperative serum creatinine level (odds ratio ϭ 1.42 [1.20, were not extubated in the OR had a lower preoperative forced 1.69], p Ͻ 0.001), and preoperative FEV1 (per 1 unit decrease [odds expiratory volume in 1 second (FEV1), lower forced vital capacity ratio ϭ 1.47 (1.23, 1.72), p Ͻ 0.001]) as well as the extent of the (FVC), lower preoperative hematocrit and albumin, and higher lung resection for segmental lung resection, lobectomy, and com- preoperative creatinine. plete pneumonectomy (more extensive lung resection was predic- The median intubation time in the OR was 3.9 hours (with tive of postoperative ventilation, Table 3 and Fig 1). 25th and 75th percentile of 3.0 and 5.0 hours). The median postoperative intubation time (total intubation time minus the DISCUSSION OR intubation time) was 7.93 hours, with the 25th percentile Early postoperative extubation after lung resection is desir- being 2.75 hours and the 75th percentile 20.67 hours for pa- able because it saves medical resources and may help to avoid tients who were not extubated in the OR. ventilator-related complications.6 An ability to identify periop- 768 CYWINSKI ET AL Table 2. Comparison of Patients Who Were Extubated in the OR Versus Those Who Arrived to a Recovery Area Intubated Based on Continuous
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