Is Nocturnal Extubation After Cardiac Surgery Associated With Worse Outcomes?
Journal
The Annals of thoracic surgery
ISSN: 1552-6259
Titre abrégé: Ann Thorac Surg
Pays: Netherlands
ID NLM: 15030100R
Informations de publication
Date de publication:
01 2019
01 2019
Historique:
received:
19
11
2017
revised:
30
05
2018
accepted:
25
06
2018
pubmed:
21
10
2018
medline:
11
10
2019
entrez:
21
10
2018
Statut:
ppublish
Résumé
There is an increased risk of medical errors overnight compared with the day, secondary to fatigue, paucity of resources, and decreased staffing. Whether this increased risk extends to liberation from mechanical ventilation is controversial. We evaluated the relationship between length of intubation and differences between diurnal and nocturnal extubation. We studied patients who had cardiac surgical procedures between January 1, 2007, and March 31, 2016, who were intubated on arrival to the cardiovascular intensive care unit (ICU) immediately after operation. Patients were divided into those extubated 24 or fewer hours or more than 24 hours after ICU arrival and were further divided by time of extubation: daytime (7 AM to 7 PM) and nocturnal (7 PM to 7 AM). We used multivariable logistic regression to determine whether nocturnal extubation was associated with increased mortality compared with diurnal extubation. Subgroup analyses investigated the effect of laboratory values, fluid management, and infused medicines. Two hundred seventy-eight of 8,705 patients (3.2%) died in the hospital; 84 died without being extubated. Of the remaining 8,621 patients, 6,982 patients (81%) were extubated within 24 hours of arrival to the ICU. Eighty-three of the patients (1.1%) died, and the proportion did not vary between day and night. In the delayed extubation group, 127 of the 1,639 patients (7.7%) died. Nocturnal extubation was associated with increased mortality only in the patients extubated more than 24 hours after ICU admission (adjusted odds ratio 2.46, 95% confidence interval: 1.45 to 4.16, p = 0.001). This increased risk persisted through all subgroup and sensitivity analyses. Nocturnal extubation was associated with increased mortality only in the group of patients receiving more than 24 hours of mechanical ventilation.
Sections du résumé
BACKGROUND
There is an increased risk of medical errors overnight compared with the day, secondary to fatigue, paucity of resources, and decreased staffing. Whether this increased risk extends to liberation from mechanical ventilation is controversial. We evaluated the relationship between length of intubation and differences between diurnal and nocturnal extubation.
METHODS
We studied patients who had cardiac surgical procedures between January 1, 2007, and March 31, 2016, who were intubated on arrival to the cardiovascular intensive care unit (ICU) immediately after operation. Patients were divided into those extubated 24 or fewer hours or more than 24 hours after ICU arrival and were further divided by time of extubation: daytime (7 AM to 7 PM) and nocturnal (7 PM to 7 AM). We used multivariable logistic regression to determine whether nocturnal extubation was associated with increased mortality compared with diurnal extubation. Subgroup analyses investigated the effect of laboratory values, fluid management, and infused medicines.
RESULTS
Two hundred seventy-eight of 8,705 patients (3.2%) died in the hospital; 84 died without being extubated. Of the remaining 8,621 patients, 6,982 patients (81%) were extubated within 24 hours of arrival to the ICU. Eighty-three of the patients (1.1%) died, and the proportion did not vary between day and night. In the delayed extubation group, 127 of the 1,639 patients (7.7%) died. Nocturnal extubation was associated with increased mortality only in the patients extubated more than 24 hours after ICU admission (adjusted odds ratio 2.46, 95% confidence interval: 1.45 to 4.16, p = 0.001). This increased risk persisted through all subgroup and sensitivity analyses.
CONCLUSIONS
Nocturnal extubation was associated with increased mortality only in the group of patients receiving more than 24 hours of mechanical ventilation.
Identifiants
pubmed: 30342046
pii: S0003-4975(18)31493-0
doi: 10.1016/j.athoracsur.2018.06.091
pii:
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
41-46Informations de copyright
Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.