1 Llantrisant, UK 2 Carlisle, UK
EditorThe paper by Chandrasheker and colleagues1 is a valuable addition to the debate regarding the optimal postoperative management of oesophageal resection. We have followed a similar policy of early extubation following oesophagectomy and can report similar findings. Of 33 two-stage procedures done between August 2000 and March 2003, 32 (96%) have been immediately extubated and sent to high dependency unit (HDU). Two patients (6.25%) had to be re-intubated, and significant morbidity was encountered in 14 (42%). Three patients (9.1%) required intensive therapy unit (ITU) care during their in-patient stay. One patient died (in-hospital mortality 3%) as a result of acute respiratory distress syndrome (ARDS).
All patients were assessed preoperatively with pulmonary function tests, echocardiogram and arterial blood gases. However, as these do not take into account intraoperative factors such as one lung time, blood loss and hypothermia, we suggest that more dynamic criteria should be developed to identify patients suitable for immediate extubation. It has been our practice to check the arterial blood gases as the thoracotomy is closed. If the patient is not acidotic and has a near normal base deficit, they are extubated on completion of surgery. If the base excess exceeds 7.5 mmol litre1, elective ventilation is strongly considered.
Regardless of the composition and situation of the team undertaking oesophageal resection, a common frustration we all face is restrictions in critical care capacity. We agree with the findings and commend early extubation as a safe technique. It minimizes the impact of this complex surgery on ITU facilities and may benefit the patient in reducing lung trauma.
M. Rocker
T. J. Havard
A. Wagle
Llantrisant, UK
EditorWe would like to thank Rocker, Havard and Wagle for their comments on our paper.1 Although we do carry out arterial blood gas analysis during the procedure, it is not necessarily done just prior to extubation. We agree that this may help identify people who need elective ventilation.
Although we used to ensure that an intensive care bed was available, the success of early extubation means we now only book a HDU bed routinely for these patients postoperatively.
M.V. Chandrashekar
M. Irving
J. Wayman
S.A. Raimes
A. Linsley
Carlisle, UK
References
1 Chandrashekar MV, Irving M, Wayman J, Raimes SA, Linsley A. Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital. Br J Anaesth 2003; 90: 47479