RS16. Early Extubation Is Associated With Reduced Length of Stay and Improved Outcomes After Elective Aortic Surgery in the Vascular Quality Initiative (VQI)

Abstract

Variability exists in the ventilator management of vascular surgery patients undergoing open abdominal aortic procedures. This study sought to examine the variation and impact of extubation timing on length of stay (LOS) and respiratory complications after elective open aortic surgery. We hypothesized that extubation in the operating room (OpR) is driven by modifiable factors in addition to underlying pulmonary disease and is associated with improved outcomes. We studied extubation timing for 7171 patients undergoing elective open abdominal aortic aneurysm repair (OAR, 2687 [37.5%]) or suprainguinal bypass for aortoiliac artery occlusive disease (AIOD, 4484 [62.5%]) from 2010 to 2014 in the VQI. Our primary outcome was prolonged LOS (>7 days). Our secondary outcome was respiratory complications (pneumonia/reintubation). Multivariable logistic regression models were performed for each outcome to adjust for confounding factors, and χ2 analysis was done to identify factors contributing most to the variability of extubation timing. Mean age was 65 (standard deviation, 10.2) and 63% were male. Extubation occurred (1) in the OpR (76.3%), (2) <12 hours (10.9%), (3) 12-24 hours (7.2%), and (4) >24 hours (5.6%) after surgery. When separated by case volume, centers in the top quartile (>140 cases) had the highest percentage of patients extubated in the OpR (82.1%). Patients least likely to be extubated in the OpR were older and were more likely to have COPD, require vasopressors, have higher estimated blood loss (EBL), and longer procedure times. After adjustment for patient, procedure, and institutional factors, delayed extubation was associated with prolonged LOS and pulmonary complications compared to those extubated in the OpR (Table). When limiting our analysis to groups 1 and 2, extubation out of the OpR but within 12 hours was still associated with increased LOS >7 days (odds ratio [OR], 1.4; 95% CI 1.2-1.7) and pulmonary complications (OR, 1.9; 95% CI, 1.4-2.6). When determining the factors that are associated with extubation in the OpR, VQI region (27%) was responsible for the most variability, with EBL (18%), procedure time (17%), procedure type (12%), and center volume (8%) contributing to a lesser extent (Fig). Extubation in the OpR is associated with shorter LOS and morbidity after aortic surgery. Region and center volume account for over a third of extubation timing, similar to factors associated with case complexity. These data advocate for standardized pathways for perioperative respiratory care to reduce variation, improve outcomes, and reduce costs.TableMultivariate analysis with length of stay (LOS) and pulmonary complications as primary and secondary outcomesLOS >7 daysPulmonary complicationsOR (95% CI)OR (95% CI)Extubation timing In operating room1.0 (Ref)1.0 (Ref) <12 hours1.4 (1.2-1.7)1.9 (1.4-2.6) 12-24 hours2.1 (1.7-2.7)2.6 (1.8-3.6) >24 hours5.3 (4.0-6.9)9.6 (7.1-13.0)EBL quartile <750 mL1.0 (Ref)1.0 (Ref) 750-1199 mL1.4 (1.2-1.7)1.1 (0.8-1.4) 1200-1999 mL1.3 (1.1-1.6)1.0 (0.7-1.4) >2000 mL1.4 (1.1-1.7)0.8 (0.6-1.2)Procedure time quartilea <2:451.0 (ref)1.0 (ref) 2:45 to 3:442.0 (1.7-2.4)1.8 (1.3-2.5) 3:45 to 4:592.4 (2.0-2.9)2.1 (1.5-3.0) >5:003.4 (2.7-4.2)2.0 (1.4-2.9)COPD1.3 (1.2-1.5)1.7 (1.4-2.1)Tobacco use (current vs never)0.9 (0.7-1.2)1.7 (1.0-2.8)Vasopressors required post-op2.0 (1.8-2.4)3.9 (3.1-4.8)CI, Confidence interval; COPD, chronic obstructive pulmonary disease; EBL, estimated blood loss; OR, odds ratio.aData are shown as hours:minutes. Open table in a new tab