Who Remains Intubated After Adult Spinal Deformity Surgery?

Introduction: Prolonged intubation can occur after adult spinal deformity (ASD) surgery and is helpful for patients and families to know preoperatively. For patients undergoing ASD surgery, we sought to: 1) report the rate of intubation until postoperative day 1 (POD1) and 2) report a scoring system to predict prolonged intubation.

Methods: A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009-21. All patients had 2-year follow-up. The primary outcome was prolonged intubation, until a minimum of POD1. Descriptive and univariate/multivariable logistic regression were performed.

Results: Among 233 patients undergoing ASD surgery, 36 (15.4%) required postoperative intubation until at least POD1. Of these, 50% were extubated on POD1, but 38.9% required intubation until POD2, and 11.1% until POD3. Those intubated until POD1 were older (70.3 vs. 62.4 years,p=0.001) and were more likely to have predominantly sagittal malalignment (61.3% vs. 35.0%,p=0.004) as compared to those extubated on POD0. Intraoperatively, a longer surgery (543.1 vs. 398.2 min,p < 0.001), late procedure end time (18:34 vs. 15:59,p < 0.001), change of anesthetist (55.6% vs. 30.6%,p=0.04), loss of motor potentials (16.7% vs. 2.6%,p=0.002), and greater blood loss (2808.6 vs. 1206.9,p < 0.001) were associated with prolonged intubation. Those who remained intubated, more often underwent 3-column osteotomy (30.6% vs. 15.7%,p=0.033), required greater amounts of intraoperative blood transfusion (4.8 vs.1.6 units, p< 0.001) and were less likely to be discharged home (30.3% vs. 53.6%,p=0.043). For every extra 30 minutes the case went long, the chance of intubation until POD1 increased 22% (95%CI=12%-32%,p < 0.001). The final scoring system included: age ≥61-years, sagittal malalignment, operative time>432 minutes, change of anesthetists, and procedure close time after 16:59 using univariate logistic regression and ROC analysis, which revealed a cutoff value of>3 points as a predictor of requiring intubation on POD1 (AUC=0.82,95%CI=0.74–0.89,p < 0.001,sensitivity=66.7%,specificity=85.3%).

Conclusion : Approximately 15% of patients undergoing ASD surgery remained intubated until at least POD1. A novel scoring system to predict prolonged intubation included: age ≥61-years, sagittal malalignment, operative time>432 minutes, change of anesthetists, and procedure close time after 16:59.