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Guichard L, Bhatia M. Volatile Anesthetic Agents Are Preferred Over Total Intravenous Anesthesia in Cardiac Surgery Under Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00366-5. [PMID: 38937175 DOI: 10.1053/j.jvca.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Lauriane Guichard
- Department of Anesthesiology, University of North Carolina at Chapel Hill.
| | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill
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Zajic P, Eichinger M, Eichlseder M, Hallmann B, Honnef G, Fellinger T, Metnitz B, Posch M, Rief M, Metnitz PGH. Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study. PLoS One 2023; 18:e0280820. [PMID: 36689444 PMCID: PMC9870150 DOI: 10.1371/journal.pone.0280820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
AIM OF THIS STUDY This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes. MATERIALS AND METHODS We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation. RESULTS 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation. CONCLUSIONS We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.
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Affiliation(s)
- Paul Zajic
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichinger
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Michael Eichlseder
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Hallmann
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabriel Honnef
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Tobias Fellinger
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Barbara Metnitz
- Austrian Center for Documentation and Quality Assurance in Intensive Care, Vienna, Austria
| | - Martin Posch
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Martin Rief
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Philipp G. H. Metnitz
- Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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Postoperative Changes in Pulmonary Function after Valve Surgery: Oxygenation Index Early after Cardiopulmonary Is a Predictor of Postoperative Course. J Clin Med 2021; 10:jcm10153262. [PMID: 34362046 PMCID: PMC8348833 DOI: 10.3390/jcm10153262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. Results: Median age and EuroSCORE II were 71.0 years (25–75 percentile: 59.5–77.0) and 2.46 (1.44–5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122–193). PaO2/FiO2 and AaDO2/PaO2 significantly deteriorated two hours, but not immediately, after CPB (both p < 0.0001). Decreased PaO2/FiO2 and AaDO2/PaO2 were correlated with ventilation time (r2 = 0.318 and 0.435) and intensive care unit (ICU) (r2 = 0.172 and 0.267) and hospital stays (r2 = 0.164 and 0.209). Early and delayed extubations (<6 and >24 h) were predicted by PaO2/FiO2 (377.2 and 213.1) and AaDO2/PaO2 (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700–0.911 and 0.677–0.859). Conclusions: PaO2/FiO2 and AaDO2/PaO2 two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations.
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Lloyd-Donald P, Lee WS, Hooper JW, Lee DK, Moore A, Chandra N, McCall P, Seevanayagam S, Matalanis G, Warrillow S, Weinberg L. Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative. BMC Res Notes 2021; 14:201. [PMID: 34022969 PMCID: PMC8140586 DOI: 10.1186/s13104-021-05620-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/15/2021] [Indexed: 12/13/2022] Open
Abstract
Objective Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure. Results We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).
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Affiliation(s)
| | - Wen-Shen Lee
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - James W Hooper
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University School of Medicine, Seoul, Korea
| | - Alice Moore
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - Nikhil Chandra
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
| | - Peter McCall
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
| | - Stephen Warrillow
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia. .,Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Australia.
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Maj G, Regesta T, Campanella A, Cavozza C, Parodi G, Audo A. Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:766-775. [PMID: 33840614 DOI: 10.1053/j.jvca.2021.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context. DESIGN NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery. RESULTS Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality. CONCLUSION Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.
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Affiliation(s)
- Giulia Maj
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| | - Tommaso Regesta
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Antonio Campanella
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Corrado Cavozza
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giovanni Parodi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Andrea Audo
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Abstract
Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.
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Barozzi L, Biagio LS, Meneguzzi M, Courvoisier DS, Walpoth BH, Faggian G. Novel, digital, chest drainage system in cardiac surgery. J Card Surg 2020; 35:1492-1497. [PMID: 32436655 PMCID: PMC7383877 DOI: 10.1111/jocs.14629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A new, self-contained, digital, continuous pump-driven chest drainage system is compared in a randomized control trial to a traditional wall-suction system in cardiac surgery. METHODS One hundred and twenty adult elective cardiac patients undergoing coronary artery bypass graft and/or valve surgery were randomized to the study or control group. Both groups had similar pre/intra-operative demographics: age 67.8 vs 67.0 years, Euroscore 2.3 vs 2.2, and body surface area 1.92 vs 1.91 m2 . Additionally, a satisfaction assessment score (0-10) was performed by 52 staff members. RESULTS Given homogenous intra-operative variables, total chest-tube drainage was comparable among groups (566 vs 640 mL; ns), but the study group showed more efficient fluid collection during the early postoperative phase due to continuous suction (P = .01). Blood, cell saver transfusions and postoperative hemoglobin values were similar in both groups. The study group experienced drain removal after 29.8 vs 38.4 hours in the control group (ns). Seven crossovers from the Study to the Control group were registered but no patient had drain-related complications. The Personnel Satisfaction Assessment scored above 5 for all questions asked. CONCLUSIONS The new, digital, chest drainage system showed better early drainage of the chest cavity and was as reliable as conventional systems. Quicker drain removal might impact on intensive care unit (ICU) stay and reduce costs. Additional advantages are portable size, battery operation, patient mobility, noiseless function, digital indications and alarms. The satisfaction assessment of the new system by the staff revealed a higher score when compared to the traditional wall suction chest drainage system.
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Affiliation(s)
- Luca Barozzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Livio San Biagio
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | - Matteo Meneguzzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy
| | | | - Beat H Walpoth
- Department of Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy
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Xu J, Zhou G, Li Y, Li N. Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery. BMC Pediatr 2019; 19:487. [PMID: 31829170 PMCID: PMC6907131 DOI: 10.1186/s12887-019-1832-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the outcomes of ultra-fast-track anesthesia (UFTA) and conventional anesthesia in cardiac surgery for children with congenital heart disease (CHD) and low birth weight. METHODS One hundred and ninety-four CHD children, aged 6 months to 2 years, weighting 5 to 10 kg, were selected for this study. The 94 boys and 100 girls with the American Society of Anesthesiologists (ASA) physical status III and IV were randomly divided into two groups each consisting of 97 patients, and were subjected to ultra-fast-track and conventional anesthesia for cardiac surgery. For children in UFTA group, sevoflurane was stopped when cardiopulmonary bypass (CPB) started and cis-atracurium was stopped at the beginning of rewarming, and remifentanil (0.3 μg/kg/mim) was then infused. Propofol and remifentanil were discontinued at skin closure. 10 min after surgery, extubation was performed in operating room. For children in conventional anesthesia group, anesthesia was given routinely and they were directly sent to ICU with a tracheal tube. Extubation time, ICU stay and hospital stay after operation were recorded. Sedation-agitation scores (SAS) were assessed and adverse reactions as well as other anesthesia -related events were recorded. RESULTS The extubation time, ICU stay and hospital stay were significantly shorter in UFTA group (P < 0.05) and SAS at extubation was lower in UFTA group than in conventional anesthesia group, but similar in other time points. For both groups, no airway obstruction and other serious complications occurred, and incidence of other anesthesia -related events were low. CONCLUSIONS UFTA shortens extubation time, ICU stay and hospital stay for children with CHD and does not increase SAS and incidence of adverse reactions.
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Affiliation(s)
- Jing Xu
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Guanghua Zhou
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Yanpei Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
| | - Na Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
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Lima CA, Ritchrmoc MK, Leite WS, Silva DARG, Lima WA, Campos SL, de Andrade AD. Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes. Rev Bras Ter Intensiva 2019; 31:361-367. [PMID: 31618356 PMCID: PMC7005967 DOI: 10.5935/0103-507x.20190059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 05/13/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes. METHODS This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death. RESULTS For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038). CONCLUSION Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Armele Dornelas de Andrade
- Universidade Federal do Rio Grande do Norte - Natal (RN), Brasil
- Universidade Federal de Pernambuco - Recife (PE), Brasil
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Serena G, Corredor C, Fletcher N, Sanfilippo F. Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study. World J Crit Care Med 2019; 8:28-35. [PMID: 31240173 PMCID: PMC6582226 DOI: 10.5492/wjccm.v8.i3.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/31/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.
AIM To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.
METHODS A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared “standard practice” and “intervention” periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24th postoperative hour.
RESULTS Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).
CONCLUSION The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.
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Affiliation(s)
- Giovanni Serena
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Carlos Corredor
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Nick Fletcher
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
| | - Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Intensive Care Directorate – St Georges Healthcare NHS Foundation Trust, London SW170QT, United Kingdom
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Macaire P, Ho N, Nguyen T, Nguyen B, Vu V, Quach C, Roques V, Capdevila X. Ultrasound-Guided Continuous Thoracic Erector Spinae Plane Block Within an Enhanced Recovery Program Is Associated with Decreased Opioid Consumption and Improved Patient Postoperative Rehabilitation After Open Cardiac Surgery—A Patient-Matched, Controlled Before-and-After Study. J Cardiothorac Vasc Anesth 2019; 33:1659-1667. [DOI: 10.1053/j.jvca.2018.11.021] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Indexed: 11/11/2022]
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Hanken H, Barsukov E, Göhler F, Sehner S, Smeets R, Beck-Broichsitter B, Heiland M, Kreutzer K, Gröbe A. Analysis of outcome for elderly patients after microvascular flap surgery: a monocentric retrospective cohort study. Clin Oral Investig 2019; 24:193-200. [DOI: 10.1007/s00784-019-02914-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/24/2019] [Indexed: 03/09/2023]
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Wang ZC, Chen Q, Cao H, Zhang GC, Chen LW, Yu LL, Luo ZR. Fast-Track Cardiac Anesthesia for Transthoracic Device Closure of Perimembranous Ventricular Septal Defects in Children: A Single Chinese Cardiac Center Experience. J Cardiothorac Vasc Anesth 2019; 33:1262-1266. [DOI: 10.1053/j.jvca.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Indexed: 11/11/2022]
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Tipton E, Pustejovsky JE, Ahmadi H. Current practices in meta-regression in psychology, education, and medicine. Res Synth Methods 2019; 10:180-194. [PMID: 30616301 DOI: 10.1002/jrsm.1339] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/07/2018] [Accepted: 12/18/2018] [Indexed: 12/20/2022]
Abstract
Having surveyed the history and methods of meta-regression in a previous paper, in this paper, we review which and how meta-regression methods are applied in recent research syntheses. To do so, we reviewed studies published in 2016 across four leading research synthesis journals: Psychological Bulletin, the Journal of Applied Psychology, Review of Educational Research, and the Cochrane Library. We find that the best practices defined in the previous review are rarely carried out in practice. In light of the identified discrepancies, we consider how to move forward, first by identifying areas where further methods development is needed to address persistent problems in the field and second by discussing how to more effectively disseminate points of methodological consensus.
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Affiliation(s)
- Elizabeth Tipton
- Statistics Department, Northwestern University, Evanston, Illinois, USA.,Human Development Department, Teachers College, Columbia University, New York, New York, USA
| | - James E Pustejovsky
- Educational Psychology Department, University of Texas at Austin, Austin, Texas, USA
| | - Hedyeh Ahmadi
- Human Development Department, Teachers College, Columbia University, New York, New York, USA
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Huang Q, Lin LY, Lin XZ. Comparison of Remifentanil-Based Fast-Track and Fentanyl-Based Routine Cardiac Anesthesia for Intraoperative Device Closure of Atrial Septal Defect (ASD) in Pediatric Patients. Med Sci Monit 2019; 25:1187-1193. [PMID: 30759074 PMCID: PMC6381809 DOI: 10.12659/msm.913387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background The aim of this study was to evaluate the effectiveness and safety of remifentanil-based fast-track anesthesia for intraoperative device closure of atrial septal defects (ASDs). Material/Methods The clinical data of 152 pediatric patients who received intraoperative device closure of ASD in our hospital from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into 2 groups: group F (remifentanil-based fast-track anesthesia group, n=72) and group C (fentanyl-based routine anesthesia group, n=80). The relevant data from 2 groups were collected and analyzed. Results No significant differences were found in the preoperative data or intraoperative hemodynamic index between these 2 groups. Group C was significantly inferior to group F regarding the duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, and hospitalization expenses (P<0.05). In terms of postoperative complications, no death, third-degree atrioventricular block, occluder detachment, or residual leakage was reported in either group. The incidence of lung infections and bronchospasm was significantly higher in group C than in group F. There were no anesthetic-related complications. Conclusions The application of remifentanil-based fast-track anesthesia for intraoperative device closure of ASD is as effective and safe as fentanyl-based routine anesthesia. Moreover, remifentanil-based fast-track anesthesia has the advantages of shorter duration of mechanical ventilation, shorter length of hospital and ICU stay, fewer postoperative complications, and lower hospitalization expenses, and is therefore worthy of promotion in clinical practice.
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Affiliation(s)
- Qing Huang
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Lan-Ying Lin
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Xian-Zhong Lin
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
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Hijazi EM, Edwan H, Al-Zoubi N, Radaideh H. Incidence of Nausea and Vomiting After Fast-Track Anaesthesia for Heart Surgery. Braz J Cardiovasc Surg 2019; 33:371-375. [PMID: 30184034 PMCID: PMC6122749 DOI: 10.21470/1678-9741-2018-0040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 05/29/2018] [Indexed: 12/12/2022] Open
Abstract
Objective The aim of this study was to evaluate the incidence of postoperative nausea
and vomiting (PONV) after fast-track cardiac anesthesia (FTCA) in the first
24-48 hours in the cardiac intensive care unit (CICU) after open-heart
surgery, risk factors for PONV and its influence on CICU length of stay. Methods A prospective observational study from January 1, 2013 to the end of December
2015 was performed in the CICU of a university hospital in the north of
Jordan and Queen Alia Heart Institute, Amman, Jordan. Three hundred
consecutive patients undergoing fast-track cardiac anesthesia in elective
cardiac surgery were enrolled in the study. Nausea and vomiting were
assessed after tracheal extubation, which was performed within 6-10 hours
after surgery and during the first 24-48 hours in the CICU. Metoclopramide
10 mg intravenously was used as the initial antiemetic drug, but ondansetron
4 mg intravenously was also used as second line of management. Results Nausea was reported in 46 (15.3%) patients, and vomiting in 31 (10.3%). Among
females, 38 (33.9%) patients developed nausea and 20 (17.9%) developed
vomiting. Among males, 8 (4.3%) patients developed nausea and 11 (5.9%)
developed vomiting. Conclusion PONV are relatively low after FTCA and the prophylactic administration of
antiemetic drug before anesthesia or after extubation is not necessary.
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Affiliation(s)
- Emad Mohamed Hijazi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Nabil Al-Zoubi
- General Surgery-Vascular, King Abdullah University Hospital and Jordan University of Science and Technology, Irbid, Jordan
| | - Hadi Radaideh
- General Surgery, King Abdullah University Hospital and Jordan University of Science and Technology, Irbid, Jordan
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Kotfis K, Szylińska A, Listewnik M, Lechowicz K, Kosiorowska M, Drożdżal S, Brykczyński M, Rotter I, Żukowski M. Balancing intubation time with postoperative risk in cardiac surgery patients - a retrospective cohort analysis. Ther Clin Risk Manag 2018; 14:2203-2212. [PMID: 30464493 PMCID: PMC6225847 DOI: 10.2147/tcrm.s182333] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Intubation time in patients undergoing cardiac surgery may be associated with increased mortality and morbidity. Premature extubation can have serious adverse physiological consequences. The aim of this study was to determine the influence of intubation time on morbidity and mortality in patients undergoing cardiac surgery. Methods We performed a retrospective analysis of data on 1,904 patients undergoing isolated coronary artery bypass grafting (CABG) and stratified them by duration of intubation time after surgery - 0-6, 6-9, 9-12, 12-24 and over 24 hours. Postoperative complications risk analysis was performed using multivariate logistic regression analysis for patients extubated ≤12 and >12 hours. Results Intubation percentages in each time cohort were as follows: 0-6 hours - 7.8%, 6-9 hours - 17.3%, 9-12 hours - 26.8%, 12-24 hours - 44.4% and >24 hours - 3.7%. Patients extubated ≤12 hours after CABG were younger, mostly males, more often smokers, with lower preoperative risk. They had lower 30-day mortality (2.02% vs 4.59%, P=0.002), shorter hospital stay (7.68±4.49 vs 9.65±12.63 days, P<0.001) and shorter intensive care unit stay (2.39 vs 3.30 days, P<0.001). Multivariate analysis showed that intubation exceeding 12 hours after CABG increases the risk of postoperative delirium (OR 1.548, 95% CI 1.161-2.064, P=0.003) and risk of postoperative hemofiltration (OR 1.302, 95% CI 1.023-1.657, P=0.032). Conclusion Results indicate that risk of postoperative complications does not increase until intubation time exceeds 12 hours. Shorter intubation time is seen in younger, men and smokers. Intubation time >12 hours is a risk factor for postoperative delirium and hemofiltration after cardiac surgery.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Szylińska
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| | - Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Kacper Lechowicz
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Monika Kosiorowska
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Sylwester Drożdżal
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | | | - Iwona Rotter
- Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, Szczecin, Poland,
| | - Maciej Żukowski
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
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18
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Totonchi Z, Azarfarin R, Jafari L, Alizadeh Ghavidel A, Baharestani B, Alizadehasl A, Mohammadi Alasti F, Ghaffarinejad MH. Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial. Anesth Pain Med 2018; 8:e80158. [PMID: 30533392 PMCID: PMC6240920 DOI: 10.5812/aapm.80158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/08/2018] [Accepted: 09/13/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery. METHODS This clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients' depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented. RESULTS Demographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001). CONCLUSIONS Combined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.
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Affiliation(s)
- Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Louise Jafari
- Anesthesiologist, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh Ghavidel
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahador Baharestani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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19
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Bouabdallaoui N, Stevens SR, Doenst T, Wrobel K, Bouchard D, Deja MA, Michler RE, Chua YL, Kalil RAK, Selzman CH, Daly RC, Sun B, Djokovic LT, Sopko G, Velazquez EJ, Rouleau JL, Lee KL, Al-Khalidi HR. Impact of Intubation Time on Survival following Coronary Artery Bypass Grafting: Insights from the Surgical Treatment for Ischemic Heart Failure (STICH) Trial. J Cardiothorac Vasc Anesth 2018; 32:1256-1263. [PMID: 29422280 DOI: 10.1053/j.jvca.2017.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to assess determinants of intubation time and evaluate its impact on 30-day and 1-year postoperative survival in Surgical Treatment for Ischemic Heart Failure (STICH) trial patients. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS A multivariable Cox proportional hazards model was used among the 1,446 surgical patients from the STICH trial who survived 36 hours after operation, in order to identify perioperative factors associated with 30-day and 1-year postoperative mortality. A multivariable logistic regression model was used to determine risk factors associated with intubation time. MEASUREMENTS AND MAIN RESULTS At 36 hours post-operation, 1,298 (out of 1,446) were extubated and 148 (10.2%) still intubated. Median postoperative intubation time was 11.4 hours. Among patients surviving 36 hours, a multivariable model was developed to predict 30-day (c-index = 0.88) and 1-year (c-index = 0.78) mortality. Intubation time was the strongest independent predictor of 30-day (hazard ratio [HR] 5.50) and 1-year mortality (HR 3.69). Predictors of intubation time >36 hours included mitral valve procedure, New York Heart Association class, left ventricular systolic volume index, creatinine, previous coronary artery bypass grafting (CABG), and age. Results were similar in patients surviving 24 hours post-operation, where intubation time was also the strongest predictor of 30-day (HR 4.18, c-index 0.87) and 1-year (HR 2.81, c-index 0.78) mortality. CONCLUSIONS Intubation time is the strongest predictor of 30-day and 1-year mortality among patients with ischemic heart failure undergoing CABG. Combining intubation time with other mortality risk factors may allow the identification of patients at the highest risk for whom the development of specific strategies may improve outcomes.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada.
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Krzysztof Wrobel
- Department of Cardiac Surgery, Medicover Hospital, Warsaw, Poland
| | - Denis Bouchard
- Department of Surgery, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | | | - Renato A K Kalil
- Postgraduate Program, Instituto de Cardiologia/FUC and UFCSPA, Porto Alegre, Brazil
| | - Craig H Selzman
- Department of Surgery, University of Utah, Salt Lake City, UT
| | - Richard C Daly
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Benjamin Sun
- The Minneapolis Heart Institute, Minneapolis, MN
| | | | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Eric J Velazquez
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jean L Rouleau
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
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20
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The use of Rapid Shallow Breathing Index shortens time to extubation in patients undergoing coronary artery bypass grafting. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:45-51. [PMID: 32082710 DOI: 10.5606/tgkdc.dergisi.2018.15136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 09/12/2017] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the effects of the use of the Rapid Shallow Breathing Index on extubation success and time to extubation in patients undergoing elective isolated coronary artery bypass grafting. Methods This prospective, randomized-controlled study included a total of 72 patients (55 males, 19 females; mean age 60.3±9.3 years; range 45 to 76 years) who underwent isolated coronary artery bypass grafting between February 2016 and November 2016. The patients were divided into two groups as the RSBI group (n=36) and the control group (n=36). The control group was extubated by conventional criteria that were routinely applied in our clinic, while the RSBI group was extubated, when the index scores became below 77 breaths per min/L, following ensuring hemodynamic stability and weaning procedure from mechanical ventilation. Results The mean time to wean from mechanical ventilation was 5.8±1.0 hours in the RSBI group and 8.1±2.0 hours in the control group (p=0.03). Extubation protocol performed through the use of the index was found to provide 26% earlier extubation compared to the conventional extubation criteria. There was no significant difference in the postoperative follow-up parameters or clinical conditions. Conclusion Our study results show that a practical tool such as the Rapid Shallow Breathing Index can be reliably used for making a decision in favor of extubation in patients undergoing coronary artery bypass grafting. A shortened time to extubation by the use of this index may provide substantial benefits in terms of prevention of infections, mechanical ventilation-induced lung injuries, and potential pulmonary complications.
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21
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Regenbogen SE, Cain-Nielsen AH, Norton EC, Chen LM, Birkmeyer JD, Skinner JS. Costs and Consequences of Early Hospital Discharge After Major Inpatient Surgery in Older Adults. JAMA Surg 2017; 152:e170123. [PMID: 28329352 DOI: 10.1001/jamasurg.2017.0123] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189 229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218 940 patients at 1056 hospitals), or total hip replacement (THR) (231 774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results A total of 639 943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26 482 vs $29 250 for colectomy, $44 777 vs $47 675 for CABG, and $24 553 vs $27 927 for THR; P < .001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P < .001; $6015 vs $6355 for CABG, P = .14; and $7132 vs $9552 for THR, P < .001) or readmissions ($2606 vs $2887 for colectomy, P = .16; $3175 vs $3064 for CABG, P = .67; and $1373 vs $1514 for THR, P = .93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and Relevance Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.
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Affiliation(s)
- Scott E Regenbogen
- Department of Surgery, University of Michigan, Ann Arbor2Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Anne H Cain-Nielsen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor3Department of Health Management and Policy, University of Michigan, Ann Arbor4Department of Economics, University of Michigan, Ann Arbor
| | - Lena M Chen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Integrated Delivery System, Dartmouth-Hitchcock, Hanover, New Hampshire6Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
| | - Jonathan S Skinner
- Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire7Geisel School of Medicine, Hanover, New Hampshire
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22
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Kundra TS, Kaur P, Manjunatha N. Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery. Ann Card Anaesth 2017; 20:90-92. [PMID: 28074803 PMCID: PMC5290704 DOI: 10.4103/0971-9784.197843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Context: Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay. Aims: The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients. Settings and Design: This prospective observational study was conducted in a 650-bedded tertiary cardiac center. Subjects and Methods: A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared. Statistical Analysis Used: Unpaired Student's t-test was used to compare the data. Results: The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001). Conclusions: A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.
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Affiliation(s)
- Tanveer Singh Kundra
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Parminder Kaur
- Department of Critical Care, Sir Ganga Ram Hospital, New Delhi, India
| | - N Manjunatha
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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23
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Zayat R, Menon AK, Goetzenich A, Schaelte G, Autschbach R, Stoppe C, Simon TP, Tewarie L, Moza A. Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience. J Cardiothorac Surg 2017; 12:10. [PMID: 28179009 PMCID: PMC5299681 DOI: 10.1186/s13019-017-0573-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/25/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications. METHODS From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVAD ultra ) in 13 patients. After propensity score matching, we compared the LVAD ultra group with a matched group (LVAD match ) receiving conventional anesthesia management. RESULTS Patients in the LVAD ultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival. CONCLUSION In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.
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Affiliation(s)
- Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
| | - Ares K Menon
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Andreas Goetzenich
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Gereon Schaelte
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ruediger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Christian Stoppe
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ajay Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
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24
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Diegeler A. Foreword: Fast track in aortic valve surgery. Eur Heart J Suppl 2017. [DOI: 10.1093/eurheartj/suw052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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25
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Rong LQ, Di Franco A, Gaudino M. Acute respiratory distress syndrome after cardiac surgery. J Thorac Dis 2016; 8:E1177-E1186. [PMID: 27867583 DOI: 10.21037/jtd.2016.10.74] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a leading cause of postoperative respiratory failure, with a mortality rate approaching 40% in the general population and 80% in the subset of patients undergoing cardiac surgery. The increased risk of ARDS in these patients has traditionally been associated with the use of cardiopulmonary bypass (CPB), the need for blood product transfusions, large volume shifts, mechanical ventilation and direct surgical insult. Indeed, the impact of ARDS in the cardiac population is substantial, affecting not only survival but also in-hospital length of stay and long-term physical and psychological morbidity. No patient undergoing cardiac surgery can be considered ARDS risk-free. Early identification of those at higher risk is crucial to warrant the adoption of both surgical and non-surgical specific preventative strategies. The present review focuses on epidemiology, risk assessment, pathophysiology, prevention and management of ARDS in the specific setting of patients undergoing cardiac surgery.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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26
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Chang B, Lorenzo J, Macario A. Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit. Anesthesiol Clin 2016; 33:753-70. [PMID: 26610628 DOI: 10.1016/j.anclin.2015.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
As health care costs threaten the economic stability of American society, increasing pressures to focus on value-based health care have led to the development of protocols for fast-track cardiac surgery and for delirium management. Critical care services can be led by anesthesiologists with the goal of improving ICU outcomes and at the same time decreasing the rising cost of ICU medicine.
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Affiliation(s)
- Beverly Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA.
| | - Javier Lorenzo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA
| | - Alex Macario
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA; Department of Health Research and Policy, Stanford University School of Medicine, 300 Pasteur Drive, H3580, Stanford, CA 94305-5640, USA
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27
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Abstract
BACKGROUND Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation after surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016. OBJECTIVES To determine the safety and effectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (January 2012 to May 2015), Embase (January 2012 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2012 to May 2015) and the Institute for Scientific Information (ISI) Web of Science (January 2012 to May 2015), along with reference lists of articles, to identify additional trials. We applied no language restrictions. SELECTION CRITERIA We included all randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups. We focused on the following fast-track interventions, which were designed for early extubation after surgery: administration of low-dose opioid-based general anaesthesia during cardiac surgery and use of a time-directed extubation protocol after surgery. The primary outcome was risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted study data. We contacted study authors for additional information. We calculated a Peto odds ratio (OR) for risk of mortality and used a random-effects model to report risk ratio (RR), mean difference (MD) and 95% confidence intervals (95% CIs) for all secondary outcomes. MAIN RESULTS We included 28 trials (4438 participants) in the updated review. We considered most participants to be at low to moderate risk of death after surgery. We assessed two studies as having low risk of bias and 11 studies high risk of bias. Investigators reported no differences in risk of mortality within the first year after surgery between low-dose versus high-dose opioid-based general anaesthesia groups (OR 0.53, 95% CI 0.25 to 1.12; eight trials, 1994 participants, low level of evidence) and between a time-directed extubation protocol versus usual care (OR 0.80, 95% CI 0.45 to 1.45; 10 trials, 1802 participants, low level of evidence).Researchers noted no significant differences between low-dose and high-dose opioid-based anaesthesia groups in the following postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99; eight trials, 1683 participants, low level of evidence), stroke (RR 1.17, 95% CI 0.36 to 3.78; five trials, 562 participants, low level of evidence) and tracheal reintubation (RR 1.77, 95% CI 0.38 to 8.27; five trials, 594 participants, low level of evidence).Comparisons with usual care revealed no significant differences in the risk of postoperative complications associated with a time-directed extubation protocol: myocardial infarction (RR 0.59, 95% CI 0.27 to 1.31; eight trials, 1378 participants, low level of evidence), stroke (RR 0.85, 95% CI 0.33 to 2.16; 11 trials, 1646 participants, low level of evidence) and tracheal reintubation (RR 1.34, 95% CI 0.74 to 2.41; 12 trials, 1261 participants, low level of evidence).Although levels of heterogeneity were high, low-dose opioid anaesthesia was associated with reduced time to extubation (reduction of 4.3 to 10.5 hours, 14 trials, 2486 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 0.4 to 7.0 hours, 12 trials, 1394 participants, low level of evidence). Use of a time-directed extubation protocol was associated with reduced time to extubation (reduction of 3.7 to 8.8 hours, 16 trials, 2024 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 3.9 to 10.5 hours, 13 trials, 1888 participants, low level of evidence). However, these two fast-track care interventions were not associated with reduced total length of stay in the hospital (low level of evidence). AUTHORS' CONCLUSIONS Low-dose opioid-based general anaesthesia and time-directed extubation protocols for fast-track interventions have risks of mortality and major postoperative complications similar to those of conventional (not fast-track) care, and therefore appear to be safe for use in patients considered to be at low to moderate risk. These fast-track interventions reduced time to extubation and shortened length of stay in the intensive care unit but did not reduce length of stay in the hospital.
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Affiliation(s)
- Wai‐Tat Wong
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Veronica KW Lai
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Yee Eot Chee
- Queen Mary HospitalDepartment of AnaesthesiologyPokfulamHong Kong
| | - Anna Lee
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
- The Chinese University of Hong KongHong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of MedicineShatinNew TerritoriesHong Kong
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Zettervall SL, Soden PA, Shean KE, Deery SE, Ultee KHJ, Alef M, Siracuse JJ, Schermerhorn ML. Early extubation reduces respiratory complications and hospital length of stay following repair of abdominal aortic aneurysms. J Vasc Surg 2016; 65:58-64.e1. [PMID: 27575806 DOI: 10.1016/j.jvs.2016.05.095] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early extubation after cardiac surgery is associated with decreased hospital stay and resource savings with similar mortality and has led to the widespread use of early extubation protocols. In the Vascular Quality Initiative, there is significant regional variation in the frequency of extubation in the operating room (endovascular aneurysm repair [EVAR], 77%-97%; open repair, 30%-70%) after repair of intact abdominal aortic aneurysms (AAAs). However, the effects of extubation practices on patient outcomes after repair of AAAs are unclear. METHODS All patients undergoing repair of an intact AAA in the Vascular Study Group of New England from 2003 to 2015 were evaluated. Patients undergoing concomitant procedures or conversions were excluded. Timing of extubation was stratified for EVAR (operating room, <12 hours, >12 hours) and open repair (operating room, <12 hours, 12-24 hours, >24 hours). Prolonged hospital stay was defined as >2 days after EVAR and >7 days after open repair. Univariate and multivariable analyses were completed, and independent predictors of extubation outside of the operating room were identified. RESULTS There were 5774 patients evaluated (EVAR, 4453; open repair, 1321). After both EVAR and open repair, respiratory complications, prolonged hospital stay, and discharge to a skilled nursing facility (SNF) increased with intubation time. After adjustment, the odds of complications increased with each 12-hour delay in extubation: respiratory (EVAR: odds ratio [OR], 4.3 [95% confidence interval (CI), 3.0-6.1]; open repair: OR, 1.8 [95% CI, 1.5-2.2]), prolonged hospital stay (EVAR: OR, 2.7 [95% CI, 2.0-3.8]; open repair: OR, 1.3 [95% CI, 1.1-1.4]), and discharge to SNF (EVAR: OR, 2.0 [95% CI, 1.5-2.8]; open repair: OR, 1.4 [95% CI, 1.1-1.6]). Predictors of extubation outside of the operating room after EVAR included increasing age (OR, 1.5; 95% CI, 1.2-1.8), congestive heart failure (OR, 1.9; 95% CI, 1.2-3.0), chronic obstructive pulmonary disease (OR, 2.0; 95% CI, 1.4-2.9), symptomatic aneurysm (OR, 3.8; 95% CI, 2.3-5.7), and increasing diameter (OR, 1.01; 95% CI, 1.01-1.01). After open repair, increasing age (OR, 1.4; 95% CI, 1.1-1.6), congestive heart failure (OR, 1.8; 95% CI, 1.01-3.3), dialysis (OR, 2.8; 95% CI, 1.7-70), symptomatic aneurysm (OR, 2.8; 95% CI, 1.9-4.3), and hospital practice patterns (OR, 1.01; 95% CI, 1.01-1.01) were predictive of extubation outside of the operating room. CONCLUSIONS The benefits of early extubation in cardiac patients are also seen after AAA repair. Suitable patients should be extubated in the operating room to decrease respiratory complications, length of stay, and discharge to an SNF. Early extubation protocols should be considered to reduce regional variation in extubation practices and to improve patient outcomes.
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Affiliation(s)
- Sara L Zettervall
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, George Washington University, Washington, D.C
| | - Peter A Soden
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Katie E Shean
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sarah E Deery
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Klaas H J Ultee
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Matthew Alef
- Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt
| | - Jeffrey J Siracuse
- Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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New Fast-Track Concepts in Thoracic Surgery: Anesthetic Implications. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0152-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Peterson C, Hall M. Pro: Dexmedetomidine Sedation Should Be Used Routinely for All Post-Cardiac Surgical Patients in the Intensive Care Unit. J Cardiothorac Vasc Anesth 2016; 30:1419-21. [PMID: 27640895 DOI: 10.1053/j.jvca.2016.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Carly Peterson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
| | - Michael Hall
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Ormesher DC, Antoniou SA, Neequaye S, Torella F, Antoniou GA. Fast track surgery programmes for abdominal aortic aneurysm surgery. Hippokratia 2016. [DOI: 10.1002/14651858.cd012176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- David C Ormesher
- Countess of Chester Hospital; South Mersey Arterial Network; Chester UK
| | - Stavros A Antoniou
- University Hospital of Heraklion, University of Crete; Department of Surgery; Souniou 11 Heraklion Greece 19001
| | - Simon Neequaye
- Royal Liverpool University Hospital; Liverpool Vascular and Endovascular Service; Prescot Street Liverpool UK L7 8XP
| | - Francesco Torella
- Royal Liverpool University Hospital; Liverpool Vascular and Endovascular Service; Prescot Street Liverpool UK L7 8XP
| | - George A Antoniou
- The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust; Department of Vascular and Endovascular Surgery; Manchester UK
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Papadopoulos N, El-Sayed Ahmad A, Thudt M, Fichtlscherer S, Meybohm P, Reyher C, Moritz A, Zierer A. Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation. J Cardiothorac Surg 2016; 11:55. [PMID: 27067581 PMCID: PMC4827191 DOI: 10.1186/s13019-016-0449-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/04/2016] [Indexed: 11/16/2022] Open
Abstract
Background The aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure. Methods Being one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge. Results Fast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89–6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99–7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27–6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28–7.46). Conclusions Fast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.
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Affiliation(s)
- Nestoras Papadopoulos
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Ali El-Sayed Ahmad
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Marlene Thudt
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Stephan Fichtlscherer
- Division of Cardiology, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt, Germany
| | - Patrick Meybohm
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Christian Reyher
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Anton Moritz
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Andreas Zierer
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
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Fischer MO, Courteille B, Guinot PG, Dupont H, Gérard JL, Hanouz JL, Lorne E. Perioperative Ventilatory Management in Cardiac Surgery: A French Nationwide Survey. Medicine (Baltimore) 2016; 95:e2655. [PMID: 26945353 PMCID: PMC4782837 DOI: 10.1097/md.0000000000002655] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/16/2015] [Accepted: 01/02/2016] [Indexed: 11/25/2022] Open
Abstract
Protective ventilation is associated with a lower incidence of pulmonary complications. However, there are few published data on routine pulmonary management in adult cardiac surgery. The present study's primary objective was to survey pulmonary management in this high-risk population, as practiced by anesthesiologists in France. All 460 registered France-based cardiac anesthesiologists were invited (by e-mail) to participate in an online survey in January-February 2015. The survey's questionnaire was designed to assess current practice in pre-, per-, and postoperative pulmonary management. In all, 198 anesthesiologists (43% of those invited) participated in the survey. Other than during the cardiopulmonary bypass (CPB) per se, 179 anesthesiologists (91% of respondees) [95% confidence interval (CI): 87-95] used a low-tidal-volume approach (6-8 mL/kg), whereas techniques based on positive end-expiratory pressure and recruitment maneuvers vary greatly from 1 anesthesiologist to another. During CPB, 104 (53%) [95% CI: 46-60] anesthesiologists withdrew mechanical ventilation (with disconnection, in some cases) and 97 (49%) [95% CI: 42-56] did not prescribe positive end-expiratory pressure. One hundred sixty-five (83%) [95% CI: 78-88] anesthesiologists stated that a written protocol for peroperative pulmonary management was not available. Twenty (10%) [95% CI: 6-14] and 11 (5%) [95% CI: 2-8] anesthesiologists stated that they did use protocols for ventilator use and recruitment maneuvers, respectively. The preoperative period (pulmonary examinations and prescription of additional assessments) and the postoperative period (extubation, and noninvasive ventilation) periods vary greatly from 1 anesthesiologist to another. The great majority of French cardiac anesthesiologists use a low tidal volume during cardiac surgery (other than during CPB per se). However, pulmonary management procedures varied markedly from 1 anesthesiologist to another. There is a clear need for large clinical studies designed to identify best practice in pulmonary management.
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Affiliation(s)
- Marc-Olivier Fischer
- From the Anesthesiology and Critical Care Department (M-OF, BC, J-LG, J-LH), University Hospital of Caen; EA 4650 (MOF, JLH), Caen Basse-Normandie University, Esplanade de la Paix, Caen; Anesthesiology and Critical Care Department (P-GG, HD, EL), Amiens University Medical Center, Amiens; and INSERM U 1088 (P-GG, HD, EL), University of Picardie Jules Verne, Centre Universitaire de Recherche en Santé, Amiens cedex, France
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Borracci RA, Ochoa G, Ingino CA, Lebus JM, Grimaldi SV, Gambetta MX. Routine operation theatre extubation after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg 2016; 22:627-32. [PMID: 26826715 DOI: 10.1093/icvts/ivv409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/29/2015] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. METHODS A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. RESULTS Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). CONCLUSIONS OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.
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Affiliation(s)
- Raul A Borracci
- Department of Cardiac Surgery, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina School of Medicine, Buenos Aires University, Buenos Aires, Argentina
| | - Gustavo Ochoa
- Department of Anesthesia, and Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Carlos A Ingino
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Janina M Lebus
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Sabrina V Grimaldi
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria X Gambetta
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
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Youssefi P, Timbrell D, Valencia O, Gregory P, Vlachou C, Jahangiri M, Edsell M. Predictors of Failure in Fast-Track Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1466-71. [DOI: 10.1053/j.jvca.2015.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Indexed: 01/08/2023]
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Fan H, Song F. An assessment of randomized controlled trials (RCTs) for non-communicable diseases (NCDs): more and higher quality research is required in less developed countries. Sci Rep 2015; 5:13221. [PMID: 26272174 PMCID: PMC4642521 DOI: 10.1038/srep13221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/21/2015] [Indexed: 12/21/2022] Open
Abstract
Research is crucial to implement evidence-based health interventions for control of non-communicable diseases (NCDs). This study aims to assess main features of randomized controlled trials (RCTs) for control of NCDs, and to identify gaps in clinical research on NCDs between high-income and less developed countries. The study included 1177 RCTs in 82 Cochrane Systematic reviews (CSRs) and evaluated interventions for adults with hypertension, diabetes, stroke, or heart diseases. Multivariate logistic regression analyses were conducted to explore factors associated with risk of bias in included RCTs. We found that 78.2% of RCTs of interventions for major NCDs recruited patients in high-income countries. The number of RCTs included in the CSRs was increasing over time, and the increasing speed was more noticeable for RCTs conducted in middle-income countries. RCTs conducted in less developed countries tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias. In conclusion, there is still a lack of research evidence for control of NCDs in less developed countries. To brace for rising NCDs and avoid waste of scarce research resources, not only more but also higher quality clinical trials are required in low-and-middle-income countries.
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Affiliation(s)
- Hong Fan
- Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, P.R. China
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, U.K
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Minimally invasive aortic valve replacement provides equivalent outcomes at reduced cost compared with conventional aortic valve replacement: A real-world multi-institutional analysis. J Thorac Cardiovasc Surg 2015; 149:1060-5. [PMID: 25680751 DOI: 10.1016/j.jtcvs.2015.01.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 12/30/2014] [Accepted: 01/06/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost. METHODS Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed. RESULTS A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02). CONCLUSIONS Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective.
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Abstract
PURPOSE OF REVIEW Advances in medical care have led to an increasing elderly population. Elderly individuals should be able to participate in society as long as possible. However, with an increasing age their adaptive capacity gradually decreases, specially before and after major life events (like hospitalization and surgery) making them vulnerable to reduced functioning and societal participation. Therapeutic exercise before and after surgery might augment the postoperative outcomes by improving functional status and reducing the complication and mortality rate. RECENT FINDINGS There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting preoperative exercise for thoracic, abdominal and major joint replacement surgery is effective, provided that this is offered to the high-risk patients. Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles. SUMMARY The perioperative exercise training protocol known under the name 'Better in, Better out' could be implemented in clinical care for the vulnerable group of patients scheduled for major elective surgery who are at risk for prolonged hospitalization, complications and/or death. Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials.
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Gutsche JT, Erickson L, Ghadimi K, Augoustides JG, Dimartino J, Szeto WY, Ochroch EA. Advancing Extubation Time for Cardiac Surgery Patients Using Lean Work Design. J Cardiothorac Vasc Anesth 2014; 28:1490-6. [DOI: 10.1053/j.jvca.2014.05.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Indexed: 11/11/2022]
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Khandelwal N, Dale CR, Benkeser DC, Joffe AM, Yanez ND, Treggiari MM. Variation in tracheal reintubations among patients undergoing cardiac surgery across Washington state hospitals. J Cardiothorac Vasc Anesth 2014; 29:551-9. [PMID: 25802193 DOI: 10.1053/j.jvca.2014.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The objectives of this study were to examine the variation in reintubations across Washington state hospitals that perform cardiac surgery, and explore hospital and patient characteristics associated with variation in reintubation. DESIGN Retrospective cohort study. SETTING All nonfederal hospitals performing cardiac surgery in Washington state. PARTICIPANTS A total of 15,103 patients undergoing coronary artery bypass grafting or valvular surgery between January 1, 2008 and September 30, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient and hospital characteristics were compared between hospitals that had a reintubation frequency ≥5% or<5%. Multivariate logistic regression was used to compare the odds of reintubation across the hospitals. The authors tested for heterogeneity of odds of reintubation across hospitals by performing a likelihood ratio test on the hospital factor. After adjusting for patient-level characteristics and procedure type, significant heterogeneity in reintubations across hospitals was present (p = 0.005). This exploratory analyses suggested that hospitals with lower reintubations were more likely to have more acute care days and teaching intensive care units (ICU). CONCLUSIONS After accounting for patient and procedure characteristics, significant heterogeneity in the relative odds of requiring reintubation was present across 16 nonfederal hospitals performing cardiac surgery in Washington state. The findings suggested that greater hospital volume and ICU teaching status were associated with fewer reintubations.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington.
| | - Christopher R Dale
- Division of Pulmonary and Critical Care Medicine, Swedish Medical Center, Seattle, Washington
| | | | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
| | | | - Miriam M Treggiari
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
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A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:468. [PMID: 25123092 PMCID: PMC4243831 DOI: 10.1186/s13054-014-0468-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/22/2014] [Indexed: 02/08/2023]
Abstract
Introduction Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end points in adult patients after elective cardiac surgery. Methods In a prospective, single-blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new-onset cardiac arrhythmia, low cardiac output syndrome, need for cardiopulmonary resuscitation, stroke, acute renal failure, and death. Results Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P <0.001). Median length of stay in the PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P <0.001). Of the adverse events examined, only the incidence of new-onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups. Conclusions Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step-down unit, without compromising patient safety. Trial registration ISRCTN71768341. Registered 11 March 2014.
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Abstract
Transcatheter aortic valve replacement (TAVR) is a new therapy for severe aortic stenosis now available in the United States. Initial patients eligible for TAVR are defined by high operative risk, with advanced age and multiple comorbidities. Following TAVR, patients experience acute hemodynamic changes and several possible complications, including hypotension, vascular injury, anemia, stroke, new-onset atrial fibrillation, conduction disturbances and kidney injury, requiring an acute phase of intensive care. Alongside improvements in TAVR technology and technique, improvements in care after TAVR may contribute to improved outcomes. This review presents an approach to post-TAVR critical care and identifies directions for future research.
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Affiliation(s)
- Matthew I Tomey
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
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43
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Epstein NE. A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures. Surg Neurol Int 2014; 5:S66-73. [PMID: 24843814 PMCID: PMC4023009 DOI: 10.4103/2152-7806.130674] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 11/04/2022] Open
Abstract
Background: The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients. Methods: We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations. Results: In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS. Conclusions: A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.
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Affiliation(s)
- Nancy E Epstein
- Chief of Neurosurgical Research and Education, Winthrop University Hospital, Mineola, NY 11501, USA
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Bechtel A, Huffmyer J. Anesthetic Management for Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:101-16. [DOI: 10.1177/1089253214529607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.
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Khanykin B, Siddiqi R, Jensen PF, Bigler DR, Atroshchenko GV. Comparison of Remifentanil and Low-Dose Fentanyl for Fast-Track Cardiac Anesthesia: A Prospective Randomized Study. Heart Surg Forum 2013; 16:E324-8. [DOI: 10.1532/hsf98.2013229] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> Different anesthetic techniques have been used for fast tracking in cardiac anesthesia. Remifentanil, with its unique pharmacokinetic profile, could be an ideal drug for fast tracking. Possible limitations of remifentanil are rapid onset of postoperative pain after discontinuation of the drug infusion, which may increase the risk of an ischemic event. We conducted this randomized study to compare the efficacy of remifentanil versus low doses of fentanyl in fast-track cardiac anesthesia. It has been hypothesized that remifentanil would provide a safe anesthesia with no impact on myocardial function and with positive effects on extubation time and mobilization.</p><p><b>Methods:</b> We compared the postoperative course of patients, the remifentanil group (RG) and the low-dose fentanyl group (LDFG), in whom remifentanil and low-dose fentanyl, respectively, were used for fast-track cardiac anesthesia. The study was designed as a prospective randomized study. The primary outcomes were changes in the cardiac index and creatine kinase MB fraction (CKMB), extubation times, mobilization times, and lengths of stay in the intensive care unit (ICU) and the hospital. Frequency of myocardial infarction (MI), reoperations due to excessive bleeding, renal impairment, and cerebral complications were registered as well.</p><p><b>Results:</b> Seventy-one patients were enrolled in the study, and 7 were excluded due to difficult airway, bleeding, and technical difficulties. The RG comprised 33 patients and the LDFG comprised of 31 patients. There were no differences between the groups in terms of age, Euroscore, types of surgery, extracorporeal circulation, and aortic cross-clamp time. We did not find significant difference in cardiac index, CKMB, extubation times, mobilization times, length of stay in the ICU and in the hospital between the groups. Postoperative complications such as MI, rates of reoperations, renal and cerebral complications and incidence of atrial fibrillation did not show any significant differences.</p><p><b>Conclusions:</b> Remifentanil fast-track anesthesia for cardiac patients has no negative impact on myocardial function. Both remifentanil and low-dose fentanyl are equally effective and safe for fast-track cardiac anesthesia. The study did not highlight any statistical superiority of remifentanil anesthesia over low-dose fentanyl anesthesia.</p>
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