Pushing the envelope: Routine operating room extubation in aortic surgery

<h2>Abstract</h2><h3>Objective</h3> Prolonged intubation is associated with worse outcomes and longer intensive care unit (ICU) and hospital length of stay (LOS). Extubation in the operating room for patients undergoing isolated coronary artery bypass grafting is feasible, safe, and decreases ICU and hospital LOS. Aortic root and arch procedures are lengthy and often require circulatory arrest. Here, we present our experience with the safety and feasibility of operating room extubation following simple and complex aortic surgery. <h3>Methods</h3> All consecutive patients who underwent aortic surgery from August 2023 to April 2025 were included in this descriptive study. We evaluated 30-day postoperative outcomes for patients who were extubated in the operating room and those in the ICU. Outcomes of interest were time to chair, ICU and hospital LOS, as well as reintubation and reoperation rates. <h3>Results</h3> Of the 265 patients included, 244 patients (92%) were extubated in the operating room. Cases included 46 Bentall procedures, 74 valve-sparing root replacements, 31 Ross procedures, 21 total arch replacements, and 142 hemiarches either in isolation or as combined procedures. Reoperative aortic surgery and circulatory arrest did not exclude qualifying for operating room extubation. One hundred sixty-five out of the total 265 (67.9%) patients had moderate or deep hypothermic circulatory arrest (22 to 28 °C) during aortic surgery: Of the patients who had circulatory arrest, 91.1% were extubated in the operating room (164 out of 180). Patients extubated in the operating room were out of bed earlier and ambulating quickly compared with ICU extubation: Median time from ICU arrival to sitting in the chair was 3.3 hours and 18.6 hours (<i>P</i> < .001), respectively. The median ICU and hospital LOS were 7.5 hours and 3.1 days compared with 35.6 hours and 5.8 days for operating room versus ICU extubation, respectively (<i>P</i> < .001). Thirty-day outcomes were excellent and comparable in both groups with no deaths or myocardial infarctions for operating room extubation compared with ICU extubation, respectively: atrial fibrillation (n = 49 [21.9%] vs n=9 [60%]), stroke (n = 1 [0.4%]) vs n=0), reoperation for bleeding (n = 1 vs n=0), reintubation for respiratory failure (n = 0 vs n=1), and 30-day readmission (n = 11 [4.9%] vs n=2 [11.8%]). <h3>Conclusions</h3> Routine extubation in the operating room is safe and feasible for a wide variety of patients undergoing both simple and complex aortic surgery, even when most of them undergo circulatory arrest. Operating room extubation may accelerate recovery and early ICU and hospital discharge, without increasing readmission or morbidity.