Asian Journal of Anesthesiology 57(4): 111-116, Dec.

2019
DOI:10.6859/aja.201912_57(4).0001
Research Paper

Factors Related to Delayed Extubation in Cervical Spine

Surgery in an Academic Hospital: A Retrospective Study
of 506 Patients
Manee Raksakietisak, Tummawadee Keawsai, Busara Sirivanasandha
Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Objective: The incidence of airway obstruction has been reported to be 1.2–6.1% after cervical spine
surgery and up to 27% in posterior occipito-cervical spinal fusion. Communication between the
anesthesiologist, surgeon, and staff responsible for postoperative care, and the identification of patients at
risk of airway complications are important. We aimed to determine the incidences of delayed extubation
and reintubation, and the factors related to delayed extubation after cervical spine surgery.
Methods: A review was conducted of the medical records of patients who underwent cervical spine
surgery in the orthopedic and neurosurgery units, Siriraj Hospital, between January 2012 and May 2017.
The data included demographics, perioperative airway management, postoperative airway complications
(delayed extubation and reintubation), and outcomes.
Results: Of the 506 patients analyzed, delayed extubation occurred in 116 (22.9%), and 15 (3.0%) were
reintubated. The independent related factors for delayed extubation were blood loss ≥ 300 mL (odds ratio
[OR], 2.71; 95% confidence interval [CI], 1.33–5.49); intraoperative fluid administration ≥ 2,000 mL (OR,
2.17; 95% CI, 1.08–4.36); anesthetic time ≥ 300 min (OR, 3.74; 95% CI, 1.83–7.63); and case finished
after service hours (OR, 3.18; 95% CI, 1.73–5.88).
Conclusion: The incidence of delayed extubation in cervical spine surgery patients was high, and
reintubation was common. Anesthesiologists should be cognizant of the related risk factors before
deciding between immediate or delayed extubation.
Keywords: delayed extubation, cervical spine surgery, reintubation

Introduction pooling caused by prone positioning and intravenous

Cervical spine surgery is a common procedure
in orthopedic and neurosurgery units. Postopera-
tive airway obstruction is a rare but potentially fatal
complication. The incidence of airway obstruction
has been reported to be 1.2–6.1%1-4 in cervical spine
surgery and up to 27% in posterior occipito-cervical
spinal fusion.5 The etiologies are laryngopharyngeal
edema resulting from retraction during anterior cer-
vical surgery, or mucosal edema arising from venous
fluid administration during posterior surgical surgery.6
The tracheal mucosa has been reported to demonstrate
marked edema at the C2–4 levels and for a maximal
period of 12–72 h postoperatively.7 Emergency airway
management by reintubation or tracheostomy may be
needed, but it could cause hypoxia, displacement of
instruments, respiratory tract infections, or death.
Although delaying extubation until resolution
of a mucosal edema prevents postoperative airway
obstruction, prolonged intubation has some adverse

Received: 23 July 2019; Received in revised form 16 August 2019; Accepted: 23 August 2019.
Corresponding Author: Busara Sirivanasandha, MD, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, 2 Thanon Wang Lang, Siriraj, Bangkok Noi, Bangkok 10700, Thailand. E-mail: busarasiri@gmail.com

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 Raksakietisak et al.
impacts as well. Good communication between the
anesthesiologist, surgeon, and staff responsible for
postoperative care, and the identification of patients at
risk of airway complications, are important. Factors
contributing to delayed extubation were reported by
Palumbo et al. as primary risk factors related to the
surgical procedure, and secondary risk factors such as
patient’s condition, anesthetic concerns, and institu-
tion resources.6
Pangthipampai et al. reported the contributing
factors of incidences of delayed extubation occurring
at our institute between 2002 and 2007.8 The signifi-
cant factors were age > 60 years, a neurological defi-
cit, surgery > 2 levels, duration > 180 min, and fiber-
optic intubation. Nowadays, surgical and anesthetic
techniques are more advanced, and although surgical
time has increased, there is less tissue trauma. As the
number of beds available in intensive care units (ICUs)
is limited, a decision to delay extubation should be
based on current evidence, and an institute should de-
velop extubation protocols for patient safety.9
The aims of this study were to determine the in-
cidences of delayed extubation and reintubation, and
to identify the factors related to delayed extubation
after cervical spine surgery.
Methods
Study Design
After research ethics board approval (SI
367/2016), a retrospective study was carried out by
examining the medical records of all patients who
underwent cervical spine surgery at Siriraj Hospital
between 2012 and 2017. All cervical spine operations
were performed in two surgical units: orthopedic
and neurosurgery. A total of 506 patients (253 in the
orthopedic unit, and 253 in the neurosurgery unit)
were reviewed by two investigators to minimize data
error. The collected data were patient characteristics,
perioperative data, airway management (the type of
equipment used, and the ease of intubation, as record-
ed by operators in anesthetic records), airway com-
plications (failed intubation, delayed extubation, and
reintubation), intraoperative data, and outcomes.
Delayed extubation was defined as a patient who
had not been extubated at the end of the surgery or
before leaving the operating room. The data for the
delayed extubation patients were reviewed in detail to
identify related factors.
112 Asian Journal of Anesthesiology 57(4) 2019
麻醉學雜誌57(4)-01 Manee Raksakietisak.indd 112
The other outcomes of interest included ven-
tilator days, lengths of ICU and hospital stays, and
patient discharge statuses.
Statistical Analysis
The estimated delayed intubation rate was
20% (from pilot observational study), with a 5%
type I error rate and an 80% power; the sample size
was calculated to be 246 patients. We estimated the
reintubation rate was 5% with a 2% error rate,1-4 a
2-sided type I error = 0.05, and an 80% power; us-
ing the nQuery Advisor 6.0 program (Statsols, Cork,
Ireland), the sample size was determined to be 457
patients. We collected 506 patients to accommodate
both airway-related complications (reintubation and
delayed extubation) and the possibility of dropouts
due to incomplete data.
All values were reported as a mean ± standard
deviation, median (ranges), or number (%), as appro-
priate. Univariate and multivariate logistic regressions
using the stepwise-selection method (95% confidence
interval [CI]) were performed to assess the possible
risk factors related to delayed extubation. A p-value of
< 0.05 was regarded as statistically significant. Data
were analyzed using PASW Statistics for Windows,
version 18.0 (SPSS Inc., Chicago, IL, USA).
Results
A total of 506 patients were included in the anal-
ysis. The patients’ demographic data were shown in
Table 1. The mean age of the patients was 57.4 ± 15.5
years. Mainly (67.7%) of the patients were American
Society of Anesthesiologists (ASA) classification I–II.
Mean body mass index was 24.2 ± 4.6 which was not
obese. Only 7% of the cases had systemic diseases
affecting cervical spines such as rheumatoid arthritis,
ankylosing spondylitis, and only 8.5% had histories of
cervical spine surgery in the past. The main diagnosis
was degenerative disease (70.9%) such as cervical
spondylosis myelopathy, cervical spondylosis radicu-
lopathy, and herniated nucleus pulposus. Fracture or
subluxation was 17.2%, and 7.7% of the cases were
diagnosed with tumor or infection.
From the intraoperative data (Table 2), the an-
esthetic time and the operating time was 276.6 ± 98.3
min and 201.5 ± 88.2 min, respectively. Mean intrave-
nous fluid and blood loss were 1,755 ± 1,035 mL and
246.3 ± 430.0 mL. Most of the cases (76.7%) were
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 Factors Related to Delayed Extubation in Cervical Spine Surgery

Table 1. Patients’ demographic data (n = 506) Table 2. Intraoperative data (n = 506)

Demographic characteristics Value Intraoperative characteristics Value

Age (year) 57.4 ± 15.5 Anesthetic time (min) 276.6 ± 98.3
ASA physical status classification Operative time (min) 201.5 ± 88.2
I 73 (14.4) Fluid (mL) 1,755 ± 1,035
II 170 (53.3) Estimated blood loss (mL) 246.3 ± 430.0
III/IV 173 (32.2) Number of operative levels
Sex: male 291 (57.5) 1–2 levels 388 (76.7)
BMI 24.2 ± 4.6 ≥ 3 levels 112 (22.1)
Underlying disease Upper C (C1–3) 234 (46.2)
Systemic disease affecting cervical spine 36 (7.1) Operative approaches
Hypertension 123 (45.6) Anterior 388 (76.7)
Diabetes mellitus 112 (22.1) Posterior 117 (23.1)
Heart disease 43 (8.5) Combined 1 (0.4)
Previous cervical spine surgery 43 (8.5) Intraoperative complications
Diagnosis Bradycardia 23 (4.5)
Degenerative (CSM, CSR, HNP) 359 (70.9) Hypotension 248 (49.0)
OPLL 21 (4.1) Hypertension 31 (6.1)
Fracture/subluxation 87 (17.2) Data presented as mean ± standard deviation (SD) or n (%).
Tumor 17 (3.4)
Infection 22 (4.3) choscope. Three hundred and ninety cases (77.1%)
ASA: American Society of Anesthesiologists; BMI: body mass were immediately extubated in the operating theater
index; CSM: cervical spondylosis myelopathy; CSR: cervical spon- by the anesthesiologists’ decision. About 11.5% were
dylosis radiculopathy; HNP: herniated nucleus pulposus; OPLL:
ossification of the posterior longitudinal ligament.
remained intubation more than 24 h and 3.6% were
Data presented as mean ± standard deviation (SD) or n (%). decided not to extubate and end up with tracheostomy.
The incidence of delayed extubation and reintubation
were 22.9 and 3.0%, respectively. About 36.6% of the
operated in 1–2 levels of the cervical spine and 46.2% cases were admitted in the ICU and 23.1% were need-
involved C1–3 levels. About 76.7% of operations ed ventilator support. The median of hospital length
were done in the anterior approach. The common of stay was 6 (5, 10) days.
intraoperative complication was hypotension which As shown in Table 4, from the univariable anal-
was not severe and can corrected by minimal doses ysis found the factor that may be related to delayed
of vasopressor. The inhalation agent was used for the extubation in our academic hospital were age > 65
maintenance period except for one case in our study years, ASA III–IV, history of difficult intubation, op-
that used intraoperative neuromonitoring. About neu- erative level > 3 levels, posterior surgical approach,
romuscular blocking agents, most of the cases (73.1%) involving C1–3, blood loss > 300 mL, intravenous
were received atracurium, cisatracurium 21.5% and fluid > 2,000 mL, anesthetic time > 300 min and fin-
rocuronium 2.2%. The last dose of muscle relaxant ished after standard service hours. The multivariable
usually was at least 30 min before finishing the opera- analysis was done in all related factors with a p-value
tion and the recovery from the effect of muscle relax- < 0.1. The result revealed the independent factor such
ants was assessed using subjective methods such as as an estimated blood loss ≥ 300 mL, an intraoper-
eye-opening and sustained handgrip after giving anti- ative fluid administration ≥ 2,000 mL, an anesthetic
cholinesterases (neostigmine) at the end of surgery. time ≥ 300 min, and finishing after standard service
hours were related to delayed extubation.
The airway management was shown in Table 3
which 42.2% of the cases were intubated by regular
or video laryngoscope and 32.8% by fiberoptic bron-

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 Raksakietisak et al.

Table 3. Airway management (n = 506) used for every case. The incidence of delayed extu-
bation varies with different definitions. Some authors
Parameter Value
have defined delayed extubation as an extubation
Intubation methods occurring after 24 h of intubation,1 or after 48 h of
McIntosh 134 (24.5) intubation.10 However, delayed extubation is mostly
Fiberoptic bronchoscope 166 (32.8) defined as no extubation at the end of surgery. In the
Video laryngoscope 163 (17.7) present study, only 84.6% were extubated within 24 h,
Already intubated or tracheostomy 13 (5.4) which is lower than the proportions reported by other
Other 16 (3.2) studies.1,11 Longer intubation periods are associated
with longer ICU stays and higher incidences of venti-
No data 14 (2.8)
lator associated pneumonia.
Extubation time
The need for reintubation could be caused by
Immediate extubation 390 (77.1) an airway obstruction or respiratory complications
Delayed extubation 0–24 h 38 (7.5) (pneumonia or aspiration). Reintubation increases
Delayed extubation > 24 h 58 (11.5) ventilator use, and it prolongs ICU and hospital stays.
No extubation and tracheostomy 18 (3.6) The 3% incidence of reintubation found in the present
No data 2 (0.4) study is comparable with the rates reported by other
Reintubation 15 (3.0)
studies.1,2,12 It is therefore necessary to have both a
backup extubation plan as well as airway equipment
No. of patients according to ventilator
on hand for reintubation in the event that an airway
hours
obstruction occurs.
No ventilator 389 (76.9)
Although an ASA physical status of III/IV or
Ventilator ≤ 24 h 63 (12.5) a comorbidity (such as obesity or asthma) has been
Ventilator 24–48 h 13 (2.6) shown to be related to delayed extubation by some
Ventilator ≥ 48 h 41 (8.1) studies,1,4,9,13 these factors were not found to be re-
No. of patients according to intensive care lated by other studies.13,14 In elective spine surgery,
length of stay stable comorbidities may not affect a decision to
Not admitted to ICU 321 (63.5) delay extubation. High levels of blood loss or blood
transfusion,1,13,15,16 excessive fluid administration,4,14,15
ICU stay ≤ 24 h 89 (17.6)
and prolonged anesthetic or operative times1,14-16 have
ICU stay 24–48 h 39 (7.7)
been shown to be factors that are significantly related
ICU stay ≥ 48 h 57 (11.3) to delayed extubation. In this study, the average blood
Hospital length of stay (d) 6 (5, 10) loss was only 200–300 mL, so there was no need for a
ICU: intensive care unit. large volume of crystalloid administration; too much
Data presented as mean ± standard deviation (SD), n (%), or medi-
an (ranges).
crystalloid administration could increase the degree
of cervical tissue edema. In the present study, a case
end-time after standard service hours was found to
Discussion be a highly significant factor for patients remaining
The incidences of delayed intubation and reintuba- intubated given that less experienced staff (i.e., junior
tion were 22.9 and 3.0%, respectively. The related fac- staff or anesthetic trainees) usually cover cases oc-
tors for delayed extubation were blood loss ≥ 300 mL, curring after standard service hours; this finding is in
fluid administration ≥ 2,000 mL, anesthetic time ≥ 300 concord with the results of Anastasian et al.4 Based on
min, and cases finishing after standard service hours. the present study’s data, an airway management pro-
To avoid serious postoperative airway complica- tocol after cervical spine surgery (covering the intuba-
tions such as airway edema, airway obstruction, and tion method, factors to be considered when deciding
emergency airway management in suspected difficult to delay extubation, and extubation guidelines) should
airway patients, many anesthesiologists choose to de- be developed and used to ensure patient safety and
lay extubation in patients at risks. Delayed extubation appropriate resource utilization. With this protocol the
has a significant impact on ventilator use and ICU or related factor due to finishing after standard service
intermediate-care stay, and it should not be routinely hours must be reduced.

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 Factors Related to Delayed Extubation in Cervical Spine Surgery

Table 4. Related factors for delayed extubation

Remaining Adjusted odds ratio

Extubation
intubation p-valuea (95% confidence p-valueb
(n = 390)
(n = 116) interval; lower upper)
Age group 0.016a
< 18 7 (1.8) 8 (7.0) 1
19–65 259 (64.4) 72 (62.6) 0.41 (0.07–2.49) 0.330
> 65 124 (31.8) 35 (30.4) 0.39 (0.06–2.59) 0.331
Sex: male 220 (57.0) 71 (61.2) 0.420
ASA physical status 0.001a
I/II 275 (70.9) 68 (58.7) 1
III/IV 113 (29.1) 48 (41.4) 1.57 (0.82–3.02) 0.172
BMI (kg/m2) 24.4 ± 4.5 23.7 ± 5.1 0.173
Previous surgery 32 (8.2) 11 (9.6) 0.627
Surgical approach 0.001a
Anterior 314 (80.5) 75 (65.2) 1.96 (0.83–4.61) 0.126
Posterior 76 (19.5) 40 (34.8) 1
Combined 0 1 (0)
Systemic diseases 23 (5.9) 13 (11.2) 0.051 2.16 (0.77–6.06) 0.143
a
Easy intubation 300 (92) 69 (83.1) 0.015 2.13 (0.90–5.04) 0.084
Operative level ≥ 3 levels 73 (18.9) 39 (34.2) 0.001a 0.87 (0.42–1.79) 0.697
Estimated blood loss ≥ 300 mL 63 (16.2) 60 (52.6) < 0.001a 2.71 (1.33–5.49) 0.006b
Fluid administration ≥ 2,000 mL 98 (25.1) 76 (66.7) < 0.001a 2.17 (1.08–4.36) 0.030b
a
Anesthetic time ≥ 300 min 98 (25.1) 83 (72.8) < 0.001 3.74 (1.83–7.63) < 0.001b
Involving C1–3 167 (42.8) 67 (57.8) 0.005a 1.01 (0.50–2.04) 0.981
a
Finished after standard service hours 101 (26.4) 74 (66.7) < 0.001 3.18 (1.73–5.88) < 0.001b
ASA: American Society of Anesthesiologists; BMI: body mass index.
Data are presented as mean ± SD or n (% or valid %, excluding missing data).
a
Comparison between groups using Student’s t test, chi-square test.
b
Comparison between groups using multivariate model.

This study has the inherent limitations of a ret- Acknowledgments

rospective review. There were some missing details,
such as whether a reintubation was performed due to
an obstruction, a respiratory failure, or both. In the
case of a small number of reintubations, it was not
possible to identify any related risks. A multicenter
or national study may be needed to find the true in-
cidence of, the causes of, and the factors related to,
reintubation.
Conclusion
The incidence of delayed extubation in cervical
spine surgery patients remains high, and reintubation
is common. Anesthesiologists should recognize the
related risk factors when deciding whether to immedi-
ately perform or delay extubation.
The authors thank Miss Julaporn Pooliam for her
statistical assistance and Miss Chusana Rungjindamai
for her substantial administrative support.
Funding
This research was supported by the Siriraj Re-
search Development Fund, Faculty of Medicine,
Siriraj Hospital, Mahidol University (grant number:
[IO] R016031004).
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