Original Contribution
Incidence and risk factors for early postoperative reintubations

https://doi.org/10.1016/j.jclinane.2015.12.038Get rights and content

Highlights

  • Assessed national incidence/risk factors for unanticipated postoperative reintubation.

  • Multivariate analysis of 2,970,904 cases controlled for patient risk factors.

  • Risk factors: age extremes, higher ASA status, longer operation, and thoracic surgery.

Abstract

Study objective

Reintubations are associated with significantly increased morbidity and mortality, increased hospital length of stay, and increased cost. Our aim was to assess the national incidence and associated risk factors for unanticipated early postoperative reintubations.

Design

Using the National Anesthesia Clinical Outcomes Registry (NACOR) from 2010 to 2014, multivariate logistic regression was fitted to determine if various patient, surgical, intraoperative, or provider data were associated with unanticipated early postoperative reintubations.

Setting

NACOR from 2010 to 2014.

Patients

A total of 2,970,904 cases were included. Multivariate analysis controlled for patient age, sex, and American Society of Anesthesiologists (ASA) Physical Status.

Interventions

None.

Measurements

We report odds ratios (ORs) and 95% confidence intervals (CIs) for the relative odds of an association of predictor variable with reintubations.

Main results

The incidence of unanticipated early postoperative reintubations from the NACOR database was 0.061%. Overall, reintubations were more likely in the extremes of age (age under 1 year had OR = 3.46, 95% confidence interval [CI] = 2.64-4.52 and age 80 + has OR = 1.80, 95% CI = 1.50-2.15 when compared with age 19-49 years), patients with ASA Physical Status 3 and 4 (OR = 4.06, 95% CI = 3.38-4.86 and OR = 8.65, 95% CI = 7.11-10.52, respectively, when compared with ASA 1), longer case duration (180-360 minutes OR = 13.87, 95% CI = 10.7-17.98 when compared with cases less than 60 minute duration), and cases that had a resident trainee present (OR = 1.22, 95% CI = 1.03-1.44 when compared with no resident present). Thoracic and vascular surgical procedures had the highest rates of reintubation when compared with general surgery (OR = 3.47, 95% CI = 2.81-4.28 and OR = 1.51, 95% CI = 1.24-1.82, respectively).

Conclusions

A number of risk factors correlate with an increased risk of unanticipated early postoperative reintubations, including extremes of age, patients with greater medical comorbidities, longer operations, and patients undergoing thoracic procedures.

Introduction

The national incidence for unanticipated early postoperative reintubations is not known. Most literature on reintubation analyzed critically ill patients mechanically ventilated for greater than 24 hours. In this setting, about 12% of extubations fail, leading to reintubation which is associated with an increase in intensive care unit (ICU) length of stay and mortality by as much as 50% [1], [2], [3], [4]. There is limited ability to extrapolate from these ICU data because the vast majority of surgical patients are not critical care patients, are in the immediate aftermath of a surgical procedure, and have been mechanically ventilated for a significantly shorter period.

However, there are some recent studies describing extubation failure that led to unanticipated reintubations in the early postoperative period. Reintubation in this setting usually occurs within 0-2 hours after extubation and less commonly after 24 hours [5], [6]. Mathew et al [7] evaluated more than 13,000 patients admitted to a single postanesthesia care unit (PACU) over 2 years and noted an emergent reintubation rate of 0.19%, most often following otolaryngologic procedures, and determined that 77% of reintubations were preventable. Rujirojindakul et al [8], [9] pioneered some of the initial investigations of independent risk factors for unanticipated reintubation in the PACU, specifically analyzing patient, operative, and anesthetic factors for reintubation. Commonly reported risk factors for unanticipated early postoperative reintubation include patient factors such as respiratory insufficiency, bronchospasm, chronic obstructive pulmonary disease, and, most commonly, upper airway obstruction usually secondary to laryngeal edema. Other reported risk factors include operative factors such as type of procedure (residual tumor and edema after elective craniotomies), otolaryngologic procedures, and operative time greater than 3 hours; higher American Society of Anesthesiologists (ASA) Physical Status; as well as anesthetic factors such as adverse effects of medications such as opioids and prolonged neuromuscular blockade [5], [6], [7], [10], [11], [12].

It is well established that reintubation is independently associated with morbidity and mortality in the ICU setting, and unanticipated early perioperative reintubation is a quality and improvement measure [1], [2], [13], [14], [15], [16]. Reviewing the ASA Closed Claim database since 2000 reveals that unanticipated postoperative reintubation for elective cases is a rare cause of malpractice lawsuits but is associated with serious outcomes and litigation [5]. Reintubation can lead to increased cardiac and respiratory complications, ICU admission, increased length of hospital stay, increased costs, and increased overall mortality [8], [9], [17], [18], [19]. A study published in 2011 reviewed 222,094 nonemergent, noncardiac cases from the American College of Surgeons–National Surgical Quality Improvement Program database and found that one-half of unanticipated postoperative reintubations occurred in the first 3 postoperative days and that unanticipated reintubation was an independent risk factor for 30-day mortality (adjusted odds ratio, 9.2) [20]. A recently published analysis concluded that clinically relevant procedural complications, such as aspiration, hypotension, and hypoxia, were more common in reintubated patients [21]. Despite defined and generally accepted extubation criteria, unanticipated early perioperative reintubation occurs with an unknown but likely significant frequency and has the potential to be associated with increased morbidity and mortality.

Expanding upon the National Surgical Quality Improvement Program study and prior investigations of risk factors for unanticipated early postoperative reintubations, this article uses the National Anesthesia Clinical Outcomes Registry (NACOR), a clinical database of more than 20 million cases as of 2014, which was originally designed for quality improvement investigations. In this article, we review the national incidence and contributing factors of unanticipated early postoperative reintubations. The goal of this study was to perform a retrospective analysis among all eligible anesthesia cases in NACOR and report the clinical predictors for unanticipated reintubations.

Section snippets

Materials and methods

NACOR is a clinical outcomes database that is recognized as a Qualified Clinical Data Registry by the Centers for Medicare and Medicaid Services for Physician Quality Reporting System. Supported by the Anesthesia Quality Institute, NACOR represents, as of 2014, more than 20 million cases from more than 200 contributing providers across the country, which include more than 15,000 anesthesiologists from 2000 different facilities. Every enlisted anesthesia practice submits administrative and

Results

There were 23,341,130 cases in the NACOR database from 2010 to 2014, in which 4,062,417 reported anesthesia-related outcomes. Out of the 2,970,904 identified cases eligible to report reintubations, there were 1806 (0.061%). Reintubations here are defined as unanticipated and occurring either intraoperatively or in the postoperative anesthesia care unit setting. A multivariate logistic regression analysis using age, ASA Physical Status, and sex as covariates demonstrates independent patient

Discussion

The incidence of unanticipated early postoperative reintubation from the NACOR database of 0.061% is less than the previous aforementioned study that quoted unanticipated reintubation within the PACU at 0.19% [7]. However, unlike the NACOR database, that study was based on data from a single institution and published two decades ago. A more recent study reported a rate of about 0.8%; however, this study additionally included reintubations occurring after PACU discharge [20]. Here we report

Acknowledgment

None.

References (24)

  • L.F. Cavallone et al.

    Review article: extubation of the difficult airway and extubation failure

    Anesth Analg

    (2013)
  • S.J. Dube et al.

    Causes of tracheal re-intubation after craniotomy: a prospective study

    Saudi J Anaesth

    (2013)
  • Cited by (33)

    • The perioperative role of high-flow cannula oxygen (HFNO)

      2023, Revue des Maladies Respiratoires
    • Thirty-Day Unplanned Reintubation Following Pleurodesis: A Retrospective National Registry Analysis

      2019, Journal of Cardiothoracic and Vascular Anesthesia
      Citation Excerpt :

      Enhanced recovery pathways likely would benefit these high-risk cohorts with guidance through the perioperative period. Reintubation has been shown to be associated with increased postoperative morbidity, intensive care unit admissions, cost, hospital stay, and mortality.3,9,11,14,15 The Centers for Medicare and Medicaid Services (CMS), a federal organization in the United States overseeing health programs, aims to align financial incentives with delivery of quality health care.

    View all citing articles on Scopus

    Disclosures: Authors have nothing to disclose. No funding was involved in this research.

    1

    These authors contributed equally to the manuscript.

    2

    Mailing address: 75 Francis St, Department of Anesthesia, Boston, MA 02115.

    View full text