Risk Factors For Reintubation After Anterior Cervical Discectomy and Fusion

Summary by Sameam Shahrestani DO, 11.1.22
https://pubmed.ncbi.nlm.nih.gov/31571118/#:~:text=Risk%20factors%20for%20reintubation%20included,or%20more%20than%20one%20anticoagulant



Take Home Point:

  • Reintubation incidence is overall low (0.19-0.21%)

  • The factors associated with increased risk of reintubation following ACDF include

    • High comorbidity burden

    • Older age

    • Male sex

    • Medicaid insurance

    • Surgery performed at large hospitals

    • Non-elective surgery

    • Anticoagulant use

  • Administration of anticoagulants increased the odds of reintubation within the first 24 hours following ACDF, possibly a consequence of their association with increased risk of hematoma development

  • Preventive measures, including steroid use or delayed extubation, have shown to lower the odds of reintubation following ACDF, and may therefore be useful in patients considered to be at higher risk for reintubation.

Summary:

Background:

This study aimed to identify risk factors that are associated with reintubation within one day following anterior cervical discectomy and fusion (ACDF).

Methods:

This was a retrospective cohort study. Data on patients who underwent ACDF surgery were extracted (and analyzed) separately from three complementary data sources. Data sources included a high volume institution, the NSQIP database, and the Premier Healthcare database. Risk factors of interest included those potentially associated with hematoma (perioperative coagulation profile: low platelets, international normalized ratio [INR], prothrombin time [PT], partial thromboplastin time [PTT], anticoagulant use), and swelling (tissue trauma associated with surgery, prolonged operation, number of vertebrae fused, and steroid use that may decrease swelling) as well as patient and hospital characteristics. In general, patients who were under 18 yr of age or with missing information on sex were excluded. Separate multivariable logistic regression models using the NSQIP and Premier samples were used to identify risk factors for reintubation within one day of ACDF. Odds ratios (OR) and 95% confidence intervals (CI) were reported.

Results:

Incidence of reintubation within one day of ACDF was 0.19% in the institutional database and 0.21% in NSQIP and Premier databases. After adjusting for all other covariates, the NSQIP data identified older age (OR, 1.03; 95% CI, 1.02 to 1.05; P < 0.001) and American Society of Anesthesiologists (ASA) class of III or higher (OR, 2.18; 95% CI, 1.35 to 3.35; P = 0.002) as risk factors for emergency reintubation following ACDF surgery. In the Premier database, male sex (OR, 1.79; 95% CI, 1.47 to 2.19; P < 0.001), Medicaid insurance (OR, 1.63; 95% CI, 1.2 to 2.21; P = 0.002), procedures performed at large hospitals (OR, 2.78; 95% CI, 1.37 to 5.64; P = 0.005), procedures performed in 2012 (OR, 2.81; 95% CI, 1.67 to 4.75; P < 0.001), non-elective (urgent) surgeries (OR, 6.02; 95% CI, 4.68 to 7.75; P < 0.001), high comorbidity burden (OR, 1.32; 95% CI, 1.26 to 1.39; P < 0.001; per unit increase in Deyo index), and use of heparin (OR, 3.24; 95% CI, 2.46 to 4.25; P < 0.001) or multiple anticoagulants (OR, 5.34; 95% CI, 3.22 to 8.85; P < 0.001) were identified as risk factors for reintubation. Steroid use (OR, 0.45; 95% CI, 0.36 to 0.56; P < 0.001) and delayed extubation (OR, 0.28; 95% CI, 0.16 to 0.49; P < 0.001) were associated with decreased odds of reintubation following ACDF. Model c-statistics were 0.74 and 0.94 for those using the NSQIP and Premier data sets.

Conclusion:

Across three complementary data sets, incidence of reintubation within one day of ACDF was approximately 0.20%. The risk factors for reintubation included high comorbidity burden, older age, male sex, Medicaid insurance, surgery performed at large hospitals, non-elective surgery, and anticoagulant use, suggesting upper airway hematoma as an underlying etiology. Preventive measures, including steroid use or delayed extubation, have shown to lower the odds of reintubation following ACDF, and may therefore be useful in patients considered to be at higher risk for reintubation.