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A Mary Kay Jiricka, RN, MSN, APN-BC, replies:
Cardiovascular surgery, whether coronary artery bypass grafting or valvular repair or replacement, continues to be a mainstay of treatment for individuals who experience coronary artery disease and/or valvular disease. Critical care nurses have always been the center of care for this patient population. In this capacity, nurses have been responsible for all aspects of patient care. In the immediate postoperative phase, critical care nurses have been responsible for assessing and monitoring the patient’s response to recovery from anesthesia, hemodynamic monitoring, administration of intravenous fluids, titration of vasoactive therapy, and the weaning and extubation from mechanical ventilator support. In the later phases of recovery, nurses are responsible for assessing the patient’s response to activity and education regarding lifestyle changes the individual may need to make as he or she recovers from surgery.
Cardiovascular surgery impairs pulmonary function and alters gas exchange and thus places patients at risk for postoperative pulmonary complications. To alleviate potential complications, it was thought that better outcomes could be achieved if a patient was intubated and received mechanical ventilation over night. The reasons for keeping patients intubated and receiving mechanical ventilation include the provision of good pain control, decreased work of breathing, better gas exchange, decreased episodes of respiratory insufficiency, less hypertension, protection from myocardial ischemia, and less anxiety.1–3 However, patients who keep receiving mechanical ventilator support are not without risk of complications such as decreased lung volumes, atelectasis, potential for the development of nosocomial pneumonia, and delays in initiating activity regimens.
In the 1990s, the practice of early and/or fast track extubation began to be investigated. Early extubation has been defined as 6 to 8 hours after surgery, with some centers extubating patients within 2 hours of arrival in the intensive care unit (ICU) and other centers even extubating patients in the operating room arena. Driving forces to decrease extubation time centered on economical issues and resource utilization. Yet, as this practice change was examined, the intent of not compromising patient care remained in the forefront. Over the years, advances in anesthesia administration, surgical techniques, extracorporeal perfusion techniques, and improved perioperative management all contributed to the success of early extubation in the cardiovascular surgical population.
One of the major reasons for the success of this practice change centers on changes in the use of anesthetic agents, mainly the use of short-acting intravenous agents, such as fentanyl, rocuronium bromide, midazolam, and sevoflurane.4,5 In programs that have fast track extubation protocols, anesthetic regimens have shorter recovery times that lead to earlier extubation. Recent research has indicated that the use of volatile anesthetics may have direct cardioprotective properties and beneficial effects to prevent myocardial reperfusion injury.4
Early extubation practices are becoming more commonplace. Initially, one reason to extubate patients early centered on cost savings issues, because early extubation has been found to lead to shorter ICU stays and an overall shorter hospital length of stay. One study6 reported an average decrease in the ICU stay by 4 hours and the overall hospital stay decreased by 1 day.
In addition to cost savings, research has shown that there is no increased morbidity and mortality associated with patients who are extubated within 8 hours of surgery. Other benefits have also been identified, including the initiation of early activity regimens. Patients who are extubated soon after surgery will often have monitoring catheters (arterial and pulmonary artery catheters) removed, allowing for freedom of movement. In research studies that measured pain, patients who were extubated early were found to have less pain than patients who remained intubated for 24 hours after surgery.3,6,7 With early activity and a decreased length of stay, patients can experience improved cardiac function as well as lessen their chance of developing nosocomial complications. Also, studies have shown that shorter lengths of hospital stay promote an earlier return to a patient’s usual activities and employment.6
To successfully implement an early weaning program, an interdisciplinary approach is needed. Weaning protocols need to be developed along with possible changes in surgical and anesthetic practices. Members of the interdisciplinary team should include physicians, anesthesiologists, nurses, therapists, and members of the quality management/improvement committee. It is imperative that weaning protocols include parameters that are measurable and easy to implement by bedside nurses. Criteria for early extubation include the patient being conscious, normothermic, nonbleeding, and hemodynamically stable (normotensive, heart rate <120 beats per minute, no signs of decreased cardiac output, and absence of myocardial ischemia). Also, the patient’s respiratory status needs to be stable as evidenced by tidal volume greater than 5 mL/kg, PaO2 greater than 80 mm Hg, pH greater than 7.30, and a PaCO2 less than 45 mm Hg.8,9 Other measures of readiness to extubate include measurements of maximal inspiratory effort and forced respiratory capacity. Centers that have had the most success with early extubation practices have developed weaning protocols that are part of the routine postoperative physician orders. This enables critical care nurses to initiate weaning when the patient meets the criteria.
References
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