Operating room extubation: A predictive factor for 1-year survival after double-lung transplantation

https://doi.org/10.1016/j.healun.2021.01.1965Get rights and content

Background

Operating room (OR) extubation has been reported after lung transplantation (LT) in small cohorts. This study aimed to evaluate the prognosis of OR-extubated patients. The secondary objectives were to evaluate the safety of this approach and to identify its predictive factors.

Methods

This retrospective single-center cohort study included patients undergoing double lung transplantation (DLT) from January 2012 to June 2019. Patients undergoing multiorgan transplantation, repeat transplantation, or cardiopulmonary bypass during the study period were excluded. OR-extubated patients were compared with intensive care unit (ICU)-extubated patients.

Results

Among the 450 patients included in the analysis, 161 (35.8%) were extubated in the OR, and 4 were reintubated within 24 hours. Predictive factors for OR extubation were chronic obstructive pulmonary disease (COPD)/emphysema (p = .002) and cystic fibrosis (p = .005), recipient body mass index (p = .048), and the PaO2/FiO2 ratio 10 minutes after second graft implantation (p < .001). OR-extubated patients had a lower prevalence of grade 3 primary graft dysfunction at day 3 (p < .001). Eight (5.0%) patients died within the first year after OR extubation, and 49 (13.5%) patients died after ICU extubation (log-rank test; p = .005). After adjustment for OR extubation predictive factors, the multivariate Cox regression model showed that OR extubation was associated with greater one-year survival (adjusted hazard ratio = 0.40 [0.16-0.91], p = .028).

Conclusions

OR extubation was associated with a favorable prognosis after DLT, but the association should not be interpreted as causality. This fast-track protocol was made possible by a team committed to developing a comprehensive strategy to enhance recovery.

Section snippets

Methods

The Institutional Review Board of the French Society for Anesthesia and Intensive Care approved the analysis of this prospectively maintained institutional anesthesia lung transplant database (CERAR N°IRB 00010254 – 2019; June 29, 2019). Informed consent was obtained from all patients. The Foch Lung Transplant Group attests strict compliance with the International Society for Heart and Lung Transplantation ethics statement.

Results

A total of 475 patients underwent DLT at our institution during the study period. After excluding patients who did not meet the study criteria, 450 patients were included in the analysis; among them, 161 (35.8%) were extubated in the OR (Figure 1). All organs were obtained from brain-dead donors, regardless of the etiology, except 22 organs that were donated after circulatory death.

Discussion

This retrospective single-center study showed that OR extubation i) was possible for nearly one-third of patients undergoing DLT; ii) was safe; and iii) was a clinical marker of a good prognosis, as the outcomes were better in these patients than in patients extubated in the ICU. Of prime importance was that our protocol did not include the preselection of potential patients for OR extubation and considered that all patients were candidates for OR extubation and that the decision was made at

Limitations of the study

First, our study was subject to all inherent limitations of any retrospective single-center analysis. However, all the data were prospectively collected from an institutional database with strict definitions. It would be interesting to randomize patients likely requiring extubation in the OR into 2 groups: an OR extubation group and an ICU extubation group, but it seems unethical to us to continue ventilation (and sedation) if it is not necessary. Second, our study focused exclusively on

Conclusion

In conclusion, OR extubation after DLT is an option for COPD/emphysema patients (51.3% of extubated patients were in this group) and cystic fibrosis patients (36.3%) but probably should not be pursued in patients with interstitial lung disease (14.3%). The survival of patients who underwent OR extubation was higher at all time points. Moreover, OR-extubated patients suffered fewer postoperative complications, including PGD3, than ICU-extubated patients. OR extubation could be considered as a

Disclosure statement

The authors have no conflicts of interest pertinent to the paper to disclose.

This study was supported by Hospital Foch, 40 rue Worth, Suresnes, France. The sponsor played no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

References (25)

  • RJ Shah et al.

    Latent class analysis identifies distinct phenotypes of primary graft dysfunction after lung transplantation

    Chest

    (2013)
  • DT Engelman et al.

    Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations

    JAMA Surg

    (2019)
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