Weaning From a Ventilator Early Extubation Post CABG - Essay Example

Weaning from a Ventilator (Early Extubation) Post CABG Introduction: I am currently working in an intensive care unit that consists of nine beds. The unit is extremely busy, leading to full utilization of the nine beds and the facilities that are provided for the care of the critically ill patients in the unit. I am specializing in Coronary Artery Bypass Graph (CABG) high turnover. During my tenure in this unit, I have found that patients after surgery spend a long time in the intensive care unit after operation and this leads to inflated costs. In addition there is a premium on the facilities and medical equipment in this busy intensive care unit. The ventilator is one such equipment that is it in great demand and so I decided to explore if there was a possibility to wean the post-operative Coronary Artery Bypass Graft (CABG) patients from the ventilators to reduce the time patients spend in the intensive care unit, cutting down on costs and pressure on the demand for these medical units. I found that on one side there was support for the early extubation of post CABG surgery patients, but there was also opposition to it. This created in me the desire to learn more on this subject, in an effort to provide better care to the patients in this intensive care unit and in that create the possibility of extending it to post CABG surgery patients in other critical care units. The plan of action in this endeavour would be to make use of the best available research to provide evidence on the subject of early extubation of post CABG surgery patients and then link it to the clinical expertise of the management of these patients and the preferences of these patients, to arrive at the best solution to early extubation in post CABG surgery patients. This would enable providing the most appropriate healthcare to these patients and would remain embedded in the tenets of evidence based learning in providing healthcare to patients. The study would aim at collecting available evidence on the subject of early extubation of post CABG surgery patients, by studying articles in available journals in libraries and also to use medical databases like MedScape in an attempt to collect evidence that would lead to the right conclusion on the possibility of early extubation in post CABG surgery patients and should the evidence provide that it is possible, locate evidence that provides the right protocol and systems that need to be utilised when employing early extubation in post CABG surgery patients. It would also be necessary to analyse the implication that such a change would bring about among the post CABG surgery patients in the unit, as well as the whole environment of the unit. Overview of the Background of Early Extubation in Post-Operative Patients: Over the last two decades the attention of health care in the service of the communities around the world has become more focused on the cost factors in healthcare. This may have to do with the more advanced medical and surgical intervention techniques and the rising cost of healthcare. Exploring the means to reduce costs in surgical intervention has led to the fast-track surgery pathway. This procedure uses modified anaesthetic management, to allow for early extubation in post-operative patients at one to six hours after surgery. This early extubation has successfully enabled the reduction in costs by cutting the number of days the patients have to remain in the intensive care units. The extension of this fast-track surgery pathway was by natural process was extended to early extubation in cardiac surgery patients. The issue of fast track surgery pathway and early extubation in patients after surgery has its share of controversies and opposition. The arguments against early extubation of patients after surgery are founded both on the cost benefits issue and the medical implications on the patient. Early extubation in post surgery patients has ramifications on the time and resources of another critically important and busy unit of any hospital environment and that is the operation room (OR). The cost and time savings derived in one unit could be at the disadvantage of another unit. In addition there were medical benefits that the post-postoperative patients derived from early extubation, but there were also demerits that definitely needed to be given consideration in use of fast track surgery pathway for early extubation in patients after surgery. (Montes, R.F and Cheng, C.H.D. Tracheal Extubation in the Operating Room Following Cardiopulmonary Bypass is Feasible). Fast Track Cardiac Surgery: Fast track cardiac surgeries to enable early extubation in patients that have undergone cardiac surgery have become a reality because of developments in anaesthetic procedures and improvements in surgical techniques and medication protocols in cardiac surgery. The full list of these factors in making fast track cardiac surgery a reality include the use of short-acting drugs with reduced doses of narcotics, improved surgical techniques and myocardial protection, postoperative analgesia, and a total change in postoperative cardiac surgical care that has resulted in the establishment of Intensive Care Units (ICU) with dedicated medical teams and flexible clinical pathways. The key factor to early extubation in fast track cardiac surgery, however, is the perioperative anaesthetic management that makes the early extubation process possible. (Montes, R.F and Cheng, C.H.D. Tracheal Extubation in the Operating Room Following Cardiopulmonary Bypass is Feasible). Impact of Early Extubation in Costs and Outcomes on Post-Operative Patients: Any study on the impact of early extubation needs to look into two aspects and that is cost and medical benefits to post-operative patients, for if evidence were to be against these two factors, early extubation for post-operative patients becomes an exercise in futility. Cost Implications: Studies in various intensive care settings in the provision of health care like adult medical, surgical and cardiac intensive care units (ICU), have found that there is cost reduction as a result of early extubation. A study that went into the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes found that the length of stay in the intensive care units reduced from 30.5 days to 25.9 days, leading to a reduction in costs from ICU $ 92, 933 to $ 78, 624, a saving of $ 14,311 on an average for every patient. The percentage of patients requiring tracheotomy decreased from 61% to 41%. A reduction in the percentage of patients requiring more than one course of mechanical ventilation was also seen and this reduction was from 33% to 26% during their period of hospitalisation. The total cost savings, as worked out by the study was $3,440,787. The study concluded that early extubation could bring about reduction in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker. (Smyrnios, A.N. et al. (2002). Effects of a Multifaceted, Multidisciplinary, Hospital-Wide Quality Improvement Program on Weaning From Mechanical Ventilation). Evidence of reduced hospital stays in cardiac surgery on young children is also available. In a study done on children of less than thirty six months of age, who underwent congenital heart surgery, it was found that early extubation in young children who have gone through a congenital heart surgery process was possible. The study did however recommend that there was the need for further research into the subject to validate the findings. (Davis, S. et al. (2004). Factors Associated With Early Extubation After Cardiac Surgery in Young Children). Evidence of the possibility of cost reduction by early tracheal extubation in patients who have undergone CABG surgery is also available. 96 patients were broken up into two groups of 47 and 26 to study the effects of early extubation. The first group were extubated within six hours with a mean time of 4.4 hours and the second group was extubated after twelve hours with a mean time of 57.5 hours. The findings of this study included the suggestion that early tracheal extubation after coronary artery bypass grafting (CABG) may reduce intensive care unit use and cost. (Konagai, N. (2001). Evaluation for factors associated to early tracheal extubation after coronary artery bypass grafting). These studies confirm the possibility of cost reduction in early extubation in post-operative patients including the patients who have undergone CABG surgery, which is the issue for which evidence was sought after. There are arguments that this cost saving of ventilator use in the ICU, may be at the expense of time in the OR, which is the most expensive direct cost variable in CABG surgery, with early extubation in the OR. There are no studies to validate this evidence, as well as the possible reduction in ICU or hospital stay as a result of early exubation in the OR. The practise of early extubation in the OR has not gained ground because of the lack of evidence in its use. The timing of exubation has less to do with medical reasons and probably more to do with the mode of functioning and culture of the healthcare provider. (Montes, R.F and Cheng, C.H.D. Tracheal Extubation in the Operating Room Following Cardiopulmonary Bypass is Feasible). Medical Implications: The medical implications are more important than cost objectives, as the patient outcome is dependant on the medical implications. In case the medical implications for early extubation indicate an increase either in the morbidity or mortality rates of patients, then early extubation as a cost reduction measure needs to be discarded irrespective of the cost benefits. There are both medical risks and medical benefits in early extubation. Early extubation, if premature could lead to ventilatory muscle fatigue, gas exchange failure, and loss of airway protection. Prolonged mechanical ventilatory support could cause ventilator-induced lung injury, nosocomial pneumonia, oxygen toxicity, airway trauma from the endo-tracheal tube, and unnecessary sedation. (MacIntyre, N. R. (2004). Evidence-based ventilator weaning and discontinuation). There is also severe pain experienced by patients who have undergone CABG surgery, due to sternotomy/thoracotomy. To control this severe pain intense postoperative analgesia is necessary. (Mehta, Y and Kumar, S. (2004). New horizons for critical care in cardiac surgery). Respiratory depression could delay extubation and the use of analgesics could enhance the chances of respiratory depression. As a control measure analgesia is commonly withheld from post-operative CABG surgery patients and this could lead to severe patient discomfort. (Renaud, K.L. (2002). Cardiovascular surgery patients respiratory responses to morphine before extubation). Several studies undertaken provide evidence that the CABG surgery patient outcomes need not be adversely affected by early extubation. In a study conducted to evaluate the effect of a short period of mechanical ventilation of three hours versus immediate extubation within one hour of the CABG surgery on the pulmonary function, gas exchange and pulmonary complications in patients that have undergone CABG surgery the conclusion was that following of routine extubation criteria enabled safe early extubation within one after CABG surgery without giving cause for alarm of further pulmonary derangement. (Nicholson, D.J. et al. (2002). Postoperative pulmonary function in coronary artery bypass graft surgery patients undergoing early tracheal extubation: a comparison between short-term mechanical ventilation and early extubation). To establish evidence on the outcomes of post CABG surgery patients another study evaluated the safety aspects of early extubation in elderly CABG patients in community practice. The study concluded that early extubation after CABG could be achieved safely in the selected elderly patients and the use of early extubation provided for shorter hospital stays and had adverse impact on the postoperative outcomes of the patients. (Guller, U. et al. (2004). Outcomes of early extubation after bypass surgery in the elderly). Strategy Evidence has provided the basis for learning that early extubation in post CABG patients does not have adverse outcomes on the postoperative outcomes of these patients and provides the benefit of cutting down on the costs incurred by reducing the period of stay in the intensive care units as well in the overall stay in hospitals. Weaning of patients from mechanical ventilation in acute care as well as across multiple services calls for a multifaceted, multidisciplinary weaning management program. (Smyrnios, A.N. et al. (2002). Effects of a Multifaceted, Multidisciplinary, Hospital-Wide Quality Improvement Program on Weaning From Mechanical Ventilation). The reason for concern in the area of withdrawing mechanical ventilator support is now more related to the selection of the appropriate mode, which is not an easy task. (Koksal, G.M. (2004). The Effects of Different Weaning Modes on the Endocrine Stress Response). The issue then in early extubation of post-operative surgical patients lies in the choosing the right weaning methods, establishing the standards for early extubation and the protocol for the early extubation process. The suggested method and protocol for weaning is that early extubation be done in the intensive care units and not in the OR. The patients suitable for early extubation are to be selected by the intensivists, on the basis of their assessment, as they have the required knowledge and experience. The intensivists would make two rounds the intensive care unit, for the purpose of weaning. The rounds would be spaced twelve hours apart. The intensivists would not initiate the actual early extubation process. Their role would be more supervisory and guidance giving. Respiratory therapists, under the guidance of the intensivists, would do the actual extubation process. On getting the decision for early extubation for a patient, the respiratory therapist would place the patient on CPAP. Additional pressure support would be provided in combination with the CPAP and both these would be set at 5 cm H20. The patient would be monitored thirty minutes by the respiratory therapist. On the intensivist finding that extubation criteria are satisfactory, early extubation is then done. A study of the success rates of early extubation in patients would be undertaken to provide the standard for success rate of the early extubation. This benchmark would be maintained at reasonable levels of efficiency. The early extubation process and protocol would be monitored from time to time to assess the possibility of improvements and thereby elevating the standards for successful extubation. (LIBERATING THE PATIENT FROM MECHANICAL VENTILATION). Action Plan: The intensive care unit is small and therefore there is no need for any pilot study. The plans for early extubation in post CABG surgery patients in intensive care unit require administrative sanction, as there are administrative changes and budgetary implications. The first step would be to study the environment of the intensive care unit from the perspective of staffing, equipment and functioning to enable listing out the administrative changes that would be required. A report would be prepared on the basis and submitted to the intensive care unit chief for his approval and initiating steps for sanction and budgetary approval. On receipt of the same, the first step would be to look into staffing requirements and the next step would be to provide a training program for the concerned intensive care unit staff on the changes of functioning required, early weaning protocols and standards and most importantly seeking the cooperation of the concerned intensive care unit staff. Equipment purchase, if necessary, would be undertaken and after installation, testing and commissioning of the equipment the early extubation proposal for postoperative CABG patients would be ready to take off. The monitoring of the process would be the final step of the action plan. Implications: There are administrative as well as financial implications in the change over to early extubation for postoperative CABG patients in the intensive care unit. Additional staffing of specialist staff may be required, as well as additional medical equipment. Change in functioning of the intensive care unit due to the early extubation protocols is the other implication. The most important implication however would be on the patients, in that they would spend less time in the intensive care unit, as well as the hospital and spend less on the CABG surgery. Literary References Davis, S. et al. (2004). ‘Factors Associated With Early Extubation After Cardiac Surgery in Young Children’. Pediatric Critical Care Medicine. MedScape. [Online]. Available at: http://www.medscape.com/viewarticle/467255. Guller, U. et al. (2004). ‘Outcomes of early extubation after bypass surgery in the elderly’. The Annals of thoracic surgery. Vol. 77, Issue 3, Pp. 781-788. Koksal, G.M. (2004). ‘The Effects of Different Weaning Modes on the Endocrine Stress Response’. Critical Care. MedScape. [Online]. Available at: http://www.medscape.com/viewarticle/466267. Konagai, N. (2001). ‘Evaluation for factors associated to early tracheal extubation after coronary artery bypass grafting’. Kyobu geka. The Japanese journal of thoracic surgery. Vol. 54, Issue 7, Pp. 560-563. ‘LIBERATING THE PATIENT FROM MECHANICAL VENTILATION’. February 2000. PULMONARY REVIEWS.COM. [Online]. http://www.pulmonaryreviews.com/feb00/pr_feb00_weaningventilator.html. MacIntyre, N. R. (2004). ‘Evidence-based ventilator weaning and discontinuation’. Respiratory care. Vol. 49, Issue 7, Pp. 830-836. Mehta, Y and Kumar, S. (2004). ‘New horizons for critical care in cardiac surgery’. Indian Journal of Critical care Medicine. Vol. 8, Issue 1, Pp. 11-13. Montes, R.F and Cheng, C.H.D. ‘Tracheal Extubation in the Operating Room Following Cardiopulmonary Bypass is Feasible’. SOCIETY OF CARDIOVASCULAR ANESTHESIOLOGISTS. [Online]. Available at: http://www.scahq.org/sca3/newsletters/feb2001_pro_con.shtml. Nicholson, D.J. et al. (2002). ‘Postoperative pulmonary function in coronary artery bypass graft surgery patients undergoing early tracheal extubation: a comparison between short-term mechanical ventilation and early extubation’. Journal of cardiothoracic and vascular anesthesia. Vol. 1, Issue1, Pp. 27-31. Renaud, K.L. (2002). ‘Cardiovascular surgery patients respiratory responses to morphine before extubation’. Pain Management Nursing. Vol. 3, Issue 2, Pp. 53-60. Smyrnios, A.N. et al. (2002). ‘Effects of a Multifaceted, Multidisciplinary, Hospital-Wide Quality Improvement Program on Weaning From Mechanical Ventilation’. Critical Care Medicine. MedScape. [Online] Available at: http://www.medscape.com/viewarticle/439734. Read More