Protocols for Early Extubation After Cardiothoracic Surgery

Protocols for Early Extubation After Cardiothoracic Surgery AATS / STS CT Critical Care Symposium April 27, 2014 Toronto, Ontario Nevin M. Katz, M.D. Johns Hopkins University Foundation for the Advancement of CTS Care (FACTS-Care)

Disclosures No disclosures relevant to this presentation. Opinions are my own, based on 30 + years in the field of CVT surgery and critical care and my interpretation of the literature.

Perspective Cardiac Surgeon - Georgetown University 20 years Heart Transplantation Program Director Cardiothoracic Surgical Critical Care George Washington University Medical Center Johns Hopkins University Cardiovascular Surgery ICU

Perspective Creation & Development of Non-Profit Educational Foundation: FACTS-Care Development and Direction of the Annual Conferences Cardiothoracic Surgical (CTS) Critical Care 2004-2008 Cardiovascular-Thoracic (CVT) Critical Care 2009-2014 Project Director AATS ICU of the Future 2012 & 2013 Co-Director AATS Postgraduate CT Critical Care Course 2010-2014 Co-Director STS CT Critical Care Symposium 2011-2014

Johns Hopkins Hospital

Johns Hopkins New Clinical Building

Cardiovascular Surgery ICU

Rationale for Early Extubation Reduce Complications & Mortality Ventilator Associated Pneumonia 3 ½ Times Risk if Mechanical Ventilation > 72 hrs, Catheter Related Infections Early Mobilization & More Rapid Recovery Shorten ICU and Hospital Stay

Protocols for Early Extubation After Cardiothoracic Surgery The Context

A Major Challenge of CT Critical Care Trend: Increased Acuity of the Patients Older More Associated Medical Conditions More Advanced Cardiac Disease Acute MI s, CHF, Cardiomyopathies, Arrhythmias More Advanced Pulmonary Disease More Advanced Esophageal Disease More Complex Surgical & Critical Care Situations

More Complex Critical Care Situations Maximally Support Technology Now creates possibility of survival, when previously there was none! New Protocols, Side-effects & Risks New Surgical / Interventional Procedures Some suitable for high-risk patients, previously considered inoperable

Effect of Cardiopulmonary Bypass on Fluid Balance General Rule: Use of CPB Results in approximately 5% gain in total body fluid (weight) - if Cardiac & Renal Function are relatively normal.

Multi-Disciplinary CVT Critical Care Team CT Surgeons Anesthesiologists & Intensivists Critical Care Nurses & Nurse Practitioners Physician Assistants Respiratory Therapists Pharmacists Perfusionists

Initial Postop Ventilator Management Full Ventilatory Support SIMV Initial SIMV Settings Resp Rate 16 FiO 2-60% Tidal Volume 8 ml/kg (Ideal Body Weight) If ARDS Protocol 6 ml/kg (Ideal Body Weight)

Preparation for Early Extubation Rewarming Topical Rewarming Fluid Rewarming Correction of Coagulopathies Volume Replacement during Rewarming Correction of Metabolic & Electrolye Abn s Refinement of Hemodynamic Management Pacing Pharmacologic / Mechanical Support

Temperature - Rewarmed to 35.5 o C Reversal of Paralytics Neostigmine Glycopyrrolate Initial Assessment for Rapid Weaning Protocol

Clinical Criteria for Early Extubation Hemodynamics Adequate & Stable BP, Perfusion - Without high dose vasopressors - Adequate Urine Output Rhythm Stable without major ectopy Hemostasis - CT drainage low & trend appropriate Neurologic Awakened well, follows commands. Metabolic Resolution of Acidosis Temperature Rewarmed to 35.5 o C (Rx for Shivering Merepidine)

Pulmonary Criteria for Early Extubation Chest Film Mediastinum without Widening or Change Adequate Expansion of Both Lungs Absence of Major Pleural Fluid Absence of Pneumothoraces Absence of Infiltrates Minimal Pulmonary Vascular Congestion

Approaches for Early Extubation Tapering of SIMV Rate Spontaneous Breathing Trial (SBT) - T-Piece SIMV then Tapering of Pressure Support from 20 cm H 2 O SIMV Directly to Minimals : PS 5 cm H 2 O / PEEP 5 cm H 2 O

Spontaneous Breathing Trials Options T-Piece CPAP Minimals (PS 5 cm H 2 O / PEEP 5 cm H 2 O) PS 5 to Overcome Resistance of ET Tube

Stepwise Conversion of SIMV to Minimals (1) Conversion from SIMV to Pressure Support 20 cm H 2 O PEEP 5 cm H 2 O (Continue until Extubation) (2) Decrease in Pressure Support Stepwise: 20, 10, 5 cm H 2 O (PS 5 to Overcome Resistance of ET Tube)

Direct Conversion of SIMV to Minimals Conversion from SIMV to: Pressure Support 5 cm H 2 O (PS 5 to Overcome Resistance of ET Tube) PEEP 5 cm H 2 O

Pulmonary Criteria for Early Extubation (Guidelines) Mechanics Negative Inspiratory Force (NIF) < - 20 cm H 2 O Tidal Volume (TV) > 5 ml/kg Minute Ventilation < 10 l/min Vital Capacity (VC) > 10 ml/kg Respiratory Rate / Tidal Volume (Tobin Index) < 80 Oxygenation P/F Ratio (po 2 / FiO 2 ) > 200

Pulmonary Criteria for Early Extubation Successful Trial on Minimals Trial for 30 Minutes FiO 2-40% Pressure Support 5 / PEEP 5

Pulmonary Criteria for Early Extubation Successful Trial on Minimals Mechanics Tidal Volume (TV) > 5ml/kg (7 ml/kg) Minute Ventilation < 10 l/min Respiratory Rate / Tidal Volume (Tobin Index) < 80 ABG po 2 > 80 mm Hg (40% O 2 ) pco 2 30 50 mm Hg ph 7.35 7.45 (Base Excess < 4)

Pulmonary Criteria for Early Extubation Successful Trial on Minimals Final Check Neuro Assessment Appropriate Interaction & Follows Commands Hemodynamics Chest Tube Drainage

Final Preparation for Extubation Head of Bed Elevated to 60 o Final suctioning of Endotracheal Tube Suctioning of Oral Cavity Ask Patient to Cough as ET Tube Removed Assists with Clearance of Secretions

Set-up After Extubation Face Mask O 2-40% Transition to Nasal Cannula O 2-6 l/min

Post-Extubation Evaluation Minimal Use of Respiratory Accessory Muscles No Retractions Respiratory Rate < 35/min Arterial O 2 Saturation > 92% Hemodynamics Stable Pulse increase < 20 bpm Systolic BP > 90 mm Hg or increase < 30 mm Hg

Support for Marginal Respiratory Status after Extubation Initial Options BiPAP PS 5 cm H 2 O / PEEP 5 cm H 2 O High Flow Nasal Cannulae Flow 40 l/min / 100 % O 2

Goal for Early Extubation after Cardiac Surgery: Within 6 hours of ICU Admission

Meeting the Challenges The Key to Quality Improvement: Measure It!

Johns Hopkins Results Study over 3 Periods 2,061 Patients Fitch ZW, Debesa O, Ohkuma R, Duquaine D, Steppan J, Schneider EB, Whitman G. A Protocol-Driven Approach to Early Extubation After Heart Surgery. J Thorac Cardiovasc Surg. 2014; 147:1344-1350.

Extubation Within 6 Hours of ICU Admission After CABG Study at Johns Hopkins Protocol Driven Approach 1 st Period (2005-2009, n= 1174): Without Protocol 2 nd Period (Oct 2009 Aug 2011, n=631): With Protocol Reversal of Paralytics at 36 o C Extubation at 36.5 o C 3 rd Period (Sept 2011 June 2012, n=256): With Revised Protocol Sign at Bedside with Extubation Goal Reversal of Paralytics at 35.5 o C Extubation at 36 o C

Highlighting the Goal for Extubation

Extubation Within 6 Hours of ICU Admission After CABG Without Protocol (n=1174): 12% With Protocol (n=631): 24% Reversal of Paralytics at 36 o C Extubation at 36.5 o C With Protocol (n=256): 38% Sign at Bedside with Extubation Goal Reversal of Paralytics at 35.5 o C Extubation at 36 o C P < 0.01 for all groups compared to each other

JH Study Results Extubation < 6hrs with Protocol Changes 50% % Patients Extubated <6hrs (CABG Only) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% n= 1174 JHH Period 1 (1/3/2005-9/29/2009) * n= 637 JHH Period 2 (10/1/2009-8/31/2011) Ŧ n= 236 JHH Period 3 (9/1/2011-6/30/2012) * p<0.01 compared to JHH Period 1 Ŧ p<0.01 compared to JHH Period 2

Extubation Within 6 Hours of ICU Admission After CABG With Revised Protocol During Study: 38% Sign at Bedside with Extubation Goal Reversal of Paralytics at 35.5 o C Extubation at 36 o C With Above Protocol Most Recently: 60-70%

Most Recent JH Results Isolated CAB s Extubation < 6hrs

Protocols for Early Extubation after CT Surgery Summary Early Preparation with Protocol & Set Goal Reversal of Paralytics at 35.5 o C Review Clinical Criteria: Hemodynamics, Rhythm, CT Drainage Respiratory Status, Neuro Status SIMV to Minimals Direct or Stepwise 30 Minute Trial on Minimals PS 5 cm H 2 O / PEEP 5 cm H 2 O Final Check & Preparation Post-Exubation Evaluation: Resp, Hemodynamics, Neuro

References Fitch ZW, Debesa O, Ohkuma R, Duquaine D, Steppan J, Schneider EB, Whitman G. A Protocol-Driven Approach to Early Extubation After Heart Surgery. J Thorac Cardiovasc Surg. 2014; 147:1344-1350. Fitch ZW, Whitman G. Incidence, Risk, and Prevention of Ventilator- Associated Pneumonia in Adult Cardiac Surgical Patients: A Systematic Review. J Card Surg 2014;29:196-203. Reddy SLC, Grayson AD, Griffiths EM, Pullan DM, Rashid A. Logistic Risk Model for Prolonged Ventilation After Adult Cardiac Surgery. Ann Thorac Surg. 2007; 84:528-36.

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