Surgeon Q&A: “Can The Ventilator Tube Be Removed Before I Wake Up in the Intensive Care Unit?” asks Joe

Preparation for heart valve surgery is often extensive. Pre-surgery testing with blood work, chest x-rays, ultrasounds, and EKGs are just the beginning. You’ll likely meet with the surgeon and surgical team members so they can explain the entire process, from the day of surgery to what to expect once you arrive home.

Even with the best of information, one aspect of valve surgery many patients struggle with is waking up in the intensive care unit (ICU) with the breathing tube still in their throat. The first inclination is to reach for the tube to pull it out, sometimes in a panic, only to find their hands are tied down to prevent them from doing so. They are in unfamiliar surroundings with machines beeping and people they don’t know. Most patients, if given the choice, would prefer to have the breathing tube taken out in the operating room while they’re still asleep before being transferred to the intensive care unit for continuing care.

Although 24-hour ventilator times remain the quality metric for the Society of Thoracic Surgeons star-rating, surgeons are working hard to reduce ventilator times even more. Many leading cardiac centers specializing in heart valve procedures and replacements are adopting the Enhanced Recovery After Surgery (ERAS) approach. The idea is to use evidence-based practices to improve surgical care and recovery for better patient outcomes, and early extubation in the operating room is one of those approaches. Although ERAS has been applied to other types of surgeries for many years, its application to cardiac surgery is relatively new.

Advances for In-Operating Room Ventilator Tube Removal

We recently received a patient question from Joe on this topic. He asked, “I have been diagnosed with bicuspid aortic stenosis and will be undergoing surgical aortic valve replacement. Is it possible to have the ventilator tube removed before waking up in the ICU as I would like to avoid this process if possible?”

I met with Dr. Marc Gerdisch, the Chief of Cardiac Surgery at Franciscan Health in Indianapolis, Indiana, to answer Joe’s question. Dr. Gerdisch has performed thousands of cardiac surgeries and serves on the ERAS Advisory Board, making him the perfect match for Joe’s question.

Key Learnings About Early Extubation After Heart Valve Surgery

• The most important aspect of early extubation is safety. Dr. Gerdisch said that if everything is safe, the mechanics of ventilation are good. The patient is stable; they work hard to take the breathing tube out in the operating room while patients are still asleep so they don’t have to wake up in the ICU with the tube still in their mouth. “We’ve worked hard on that, the first end of it being what I said first, which is safe,” he said. “Can it be done safely? Is there a reason that the tube has to stay in? As it turns out, by virtue of multimodal effort to decrease the trauma around surgery and decrease the discomfort, we have achieved a very high rate of in-operating room extubations.”

Dr. Marc Gerdisch

• The rate of early extubation depends on the patient and the type of surgery. Dr. Gerdisch told us that in their program, they are currently at 50% for early extubations, but that number includes sick patients who may be having a third reoperation or multi-valve operations. “When we look at the folks who are a little bit more straightforward, we get closer to 70% and 80% of those folks having the tube taken out in the operating room,” he said. “First, for minimally invasive patients, it’s nearly 100%. For sternotomy patients, though, we’re still pushing over 50% for a lot of those categories of patients.” Dr. Gerdisch believes they’ve achieved that number because they do rigid sternal fixation with sternotomy patients. “Then patients are comfortable, and their breathing mechanics are immediately good,” he said. “Minimally invasive, same thing, we use special methods to address discomfort, and as a result, people are comfortable and breathing mechanics are immediately good.”

• Bleeding is another aspect when deciding on early extubation. Dr. Gerdisch said, “Second question: is there any bleeding? We actually use a specialized type of chest tube. It’s an active clearance chest tube. This is something that, as a program, we had to decide if we wanted to invest in because there’s added expense there.” He told us that after a yearlong study looking at the impact of using the active clearance chest tube, they had a statistically significant decrease in transfusion rates. “There was already a very low transfusion rate,” said Dr. Gerdisch. “We lowered it even more.” When patients don’t have bleeding and are unlikely to need blood products, it means knowing the patient is stable. “Hemodynamically, they look good,” he said. “Patient’s comfortable. We know that there’s no bleeding. Take the tube out.”

Thanks Dr. Gerdisch and the Franciscan Health team!

On behalf of Joe and our entire patient community, many thanks to Dr. Gerdisch, for investing in the people, the processes, and the technology at Franciscan Health in Indianapolis, Indiana to accelerate the removal of the breathing tube in the operating room!

Related Links:

• Rapid Recovery Protocol 2.0: What Should Heart Surgery Patients Know?
• Dr. Marc Gerdisch Q&A: Restarting the Heart After Heart Surgery

Keep on tickin!
Adam