Timing of extubation after esophagectomy

Full text

Introduction

Prior to 1995, it had been our standard practice to ventilate patients overnight after esophagectomy. Since then, however, this practice has changed. If patients are warm, hemodynamically stable, and comfortable, we have elected to extubate them early.

Aim

To study the association between time to extubation and outcome after esophagectomy.

Methods

We retrospectively reviewed the records of all esophagectomies between 1990 and 1998. Early extubation was defined as extubation within 12 h. The primary outcomes evaluated were respiratory complications, hospital mortality and length of ICU stay. Outcomes between the two time periods 1990–94 (first period) and 1995–98 (second period) were compared. In the second time period, the relationship between time to extubation and outcomes was also evaluated.

Results

There were 78 esophagectomies in the first period (1990–94) and 84 in the second period (1995–98). In the second period, more patients received epidural analgesia (64% vs 34%, P=0.001) and more patients were extubated early (41% vs 6%, P<0.001) compared to the first period. There were no significant differences in the rates of respiratory complications (27% vs 34%) and hospital mortality (6% vs 10%) when comparing the second with the first time period.

In the second time period (1995–98), 31 of the 84 patients were extubated early (median time to early extubation was 6.8 h postop). More patients in the early extubation group received epidural analgesia (90% vs 50%, P=0.001). There were again no significant differences in the rates of respiratory complications (29% vs 30%) and hospital mortality (6.7% vs 7%), but the late extubation group stayed longer in the ICU (median stay 2 days vs 1 day, P=0.006).

Conclusions

Our experience suggests that early extubation after esophagectomy in stable patients is safe, and may decrease the length of ICU stay with cost-saving implications. We believe that thoracic epidural analgesia may facilitate early extubation by enabling patients to cough and cooperate with physiotherapy in the early postoperative period.