Randomized Evaluation of Operating Room Extubation After Cardiac Surgery

This is a pragmatic, randomized controlled trial comparing OR extubation versus ICU extubation among adults undergoing elective cardiac surgery.

Inclusion criteria

• Adults (age 18+) scheduled for elective cardiac surgery requiring cardiopulmonary bypass
• Low perioperative risk defined as STS Predicted Risk of Mortality (PROM) ≤ 3% based on the latest STS Adult Cardiac Surgery Database (ACSD) Risk Calculator
• Deemed appropriate for OR extubation preoperatively by the attending cardiac surgeon
• Able to provide informed consent

Exclusion criteria

• Underlying pulmonary disease requiring use of home supplemental oxygen
• Pre-capillary pulmonary hypertension (mPAP ≥ 25 mmHg or PVR > 2 Wood units) on most recent right heart catheterization for any patient for which there is suspicion for pulmonary hypertension at the time of preoperative evaluation
• Preoperative right ventricular dysfunction greater than mild on most recent echocardiogram
• Obstructive sleep apnea with home CPAP or biPAP use or recommended use
• Neuromuscular disease associated with respiratory muscle weakness including myasthenia gravis, Lambert-Eaton myasthenic syndrome, or muscular dystrophy
• Airway abnormalities including tracheostomy, history of difficult mask ventilation, history of difficult intubation requiring fiberoptic rescue or multiple (>2) attempts, known anatomic abnormalities including limited mouth opening (< 3cm), severe micrognathia, tracheal stenosis, or tracheal compression due to mass or goiter

We will also exclude patients undergoing the following procedures:

• Transplant surgery
• Pulmonary thromboendarterectomy
• Implantation of mechanical circulatory support including LVAD, Impella, intra-aortic balloon pump, RVAD, or ECMO