Late to extubate? Risk factors & associations for delayed extubation after adult cervical deformity

BACKGROUND CONTEXT: Due to the proximity of the surgical site to important respiratory and oropharyngeal structures, patients may undergo delayed extubation after adult cervical deformity (ACD) surgery to manage postoperative airway edema/obstruction and reduce the likelihood of reintubation and other respiratory, medical, and surgical complications. PURPOSE: To evaluate the relevant predictors and relationships with delayed extubation. STUDY DESIGN/SETTING: Retrospective cohort study of prospectively collected database. PATIENT SAMPLE: A total of 164 ACD patients. OUTCOME MEASURES: HRQLs, medical complications, radiographic parameters. METHODS: Operative ACD patients with baseline (BL) and perioperative data (6W) were analyzed via descriptive statistics and means comparison analyses. Patients were grouped based on whether they experienced delayed extubation (DE), as defined by leaving the OR while still intubated, versus those who were extubated successfully in the OR (non-DE). Regression analyses identified predictors of delayed extubation and associations with perioperative complications and outcomes. RESULTS: Eighty-two patients met inclusion criteria (mean age 62.4±13.0 years, 52.4% female, mean Edmonton frailty score: 5.10±2.97, mean ACFI score: 0.30±0.16, mean CCI: 1.41±1.73). The mean operative time was 393.80±170.90 minutes, mean EBL 435.0±306.0 mL, and mean length of stay was 10.9±42.3 days. 30(36.6%) patients had a previous history of cervical surgery. Fourteen (17.1%) patients left the OR intubated, 11(78.6%) had complete 6W, and 1(7.1%) required reintubation. There were no differences between the DE cohort and non-DE cohort in terms of baseline cervical radiographic parameters or preoperative cSVA, C2-C7, or TS-CL alignment goals. DE cohort demonstrated greater Edmonton frailty scores at BL (p=0.017) as well as significantly greater EBL (p=0.021). There was a significantly greater proportion of patients with congenital scoliosis amongst those with delayed extubation(p=0.016). Smoking history also demonstrated a considerably higher rate of delayed extubation (27.3% vs 6.5%, p=0.031). Additionally, kidney disease at BL was a significant predictor of delayed extubation (OR 35.5, p=0.029). Intraoperatively, there was a significant difference in rate of blood transfusions (DE: 27.3% vs non-DE: 4.8%, p=0.12), although operative time and levels fused did not appear to significantly differ or serve as predictors. Postoperatively, there was as expected a significant difference in the rate of SICU admission (DE: 90.9% vs non-DE: 49.2%, p=0.01), although there were no significant differences in LOS. When considering the impact of degree of correction, those with increased cSVA and MGS correction postoperatively from baseline were more likely to experience delayed extubation (OR 1.1, CI 95% 1.05-1.17, p<.001; OR 1.14, CI 95% 1.05-1.24, p=0.003). Furthermore, delayed extubation was a significant predictor of increased 6W VR-Physical Scores (p=0.013) at 6W, and the DE cohort demonstrated significantly higher 6W VR-PCS and VR-MCS Scores(p=0.01, both). CONCLUSIONS: Delayed extubation may hinder the reclamation of quality of life perioperatively after necessary intervention, especially patients who undergo a large degree of correction, and certain considerations such as minimizing intraoperative blood loss and transfusions required could minimize the occurrence of delayed extubation. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.

Duke Scholars

Author Peter Passias Orthopaedic Surgery

Author Christopher Ignatius Shaffrey Orthopaedic Surgery