Is Extubating My Cardiac Surgery Patient Postoperatively in the Operating Room a Good Idea?
Following multiple episodes of shortness of breath at home, a 66-year-old man with severe mitral regurgitation undergoes an elective mitral valve repair via mini-thoracotomy. His past medical history is significant for diabetes controlled with metformin a
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Joseph Kimmel and Peter J. Neuburger
Case Following multiple episodes of shortness of breath at home, a 66-year-old man with severe mitral regurgitation undergoes an elective mitral valve repair via mini-thoracotomy. His past medical history is significant for diabetes controlled with metformin and hypertension treated with metoprolol. In the past, he was a casual tennis player, but lately he has been feeling short of breath going up the flight of stairs in his house. It is the first case of the day. Induction, intubation, and line placement are uneventful, and the surgery proceeds without incident. At the end of the case, the surgeon jokes to his assistant, “This gas man over here has the easiest job; he just hits every patient over the head with his cookbook and hopes they wake up some point later in the day.”
Question Should I tailor my anesthetic emergence to extubate the patient in the operating room at the end of the case? CON: Cardiopulmonary bypass (CPB) induces a stress response in the body evidenced by a sympathetic surge that can persist for hours postoperatively. Despite this, patients typically experience some level of stunned and hibernating myocardium post-CPB, resulting in both systolic and diastolic dysfunction. Additionally, myocardial ischemia is known to peak postoperatively 18–24 h postbypass and to J. Kimmel Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA e-mail: [email protected] P.J. Neuburger (&) Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA e-mail: [email protected]
improve with intensive analgesia [1]. Positive pressure ventilation “off-loads” the heart by decreasing afterload and left ventricular end diastolic pressure (LVEDP) and thus may increase coronary perfusion pressure (CPP). Additionally, metabolism is increased postoperatively, leading to increased production of CO2 and higher work of breathing. Therefore, mechanical ventilation can shift the myocardial oxygen supply and demand curves in favor of promoting optimal healing and favorable myocardial remodeling. PRO: First of all, the other half of the equation for coronary perfusion pressure is the aortic diastolic pressure, which can be decreased when a postbypass patient with diastolic dysfunction is exposed to positive pressure ventilation, reducing preload, and potentially stroke volume by shifting the Starling curve. Perhaps this is why the studies that showed decreased ischemia with intensive analgesia with positive pressure ventilation never showed a significant benefit in overall patient outcomes in terms of long-term ventricular function, morbidity, or mortality. In fact, the prospective randomized trials that confirmed the safety of fast-track (FT) post-CBP recovery (within 4–6 h of surgery vs. the convention of leaving patients intubated and sedated in the
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