Ultra-fast track hospital discharge using conventional cardiac surgical techniques

Fast-track off-pump coronary artery bypass: single-center experience

AIM

The primary goal of the study was to perform retrospective analysis of fast-track coronary artery bypass grafting at our institute to identify risk factors for prolonged hospital stay. A secondary goal was to identify and compare survival statistics with those published in literature.

METHOD

We performed a retrospective analysis of patients enrolled in our fast-track coronary artery bypass protocol. There were 709 patients with a mean age of 58.85 ± 8.9 years; 572 were men. The mean EuroSCORE II was 2.02% ± 2.64%. Of these 709 patients, 538 (76%) met the requirements for discharge within 100 hours.

RESULTS

Prolonged ventilation or reintubation, major pulmonary complications, gastrointestinal and neurological complications were the strongest predictors of fast-track failure. Persistent atrial fibrillation, postoperative transient renal impairment, requirement for noninvasive ventilation > 3 times, sternal wound infection, insulin-dependent diabetes mellitus, preoperative intraaortic balloon pump for chest pain or ST changes, preoperative severe left ventricular dysfunction, preoperative severe renal impairment, and peripheral arterial disease were also found to be significant risk factors for fast-track failure. Cumulative survival at 66 months of follow-up was 90.2% ± 0.02%.

CONCLUSION

The risk factors listed above were associated with fast-track failure. Smoking cessation helps to nullify the factor of chronic obstructive pulmonary disease. Intraoperative elective insertion of a balloon pump does not affect the fast-track protocol. Survival was comparable to that described in the literature.

Postoperative complications after elective coronary artery bypass grafting surgery in patients with sleep-disordered breathing

BACKGROUND

Sleep-disordered breathing (SDB) may increase the risk of postoperative complications in patients after cardiac surgery. This study evaluated the length of hospital stay as well as postoperative cardiac, respiratory, and renal complications after elective coronary artery bypass grafting (CABG) in patients without SDB, with central sleep apnea (CSA), or with obstructive sleep apnea (OSA).

METHODS

The presence and type of SDB had been assessed with polygraphic recordings in 100 patients the night before elective CABG surgery. SDB was defined as an apnea-hypopnea index (AHI) of ≥ 15/h. Prolonged length of hospital stay (LOS) and postoperative hemodynamic instability due to any cause were retrospectively evaluated as primary endpoints and cardiac, respiratory, and renal complications as secondary endpoints.

RESULTS

37% of patients had SDB, 14% CSA, and 23% OSA. LOS differed significantly between patients without SDB and those with CSA and OSA [median (25;75. percentile): 8.0 days (7.5;11.0) vs. 9.5 days (7.0;12.5) vs. 12.0 days (9.0;17.0), Kruskal-Wallis test between three groups: p = 0.023; OSA vs. no SDB: p = 0.005]. AHI was significantly associated with prolonged LOS [> 9 days; odds ratio (OR) (95% confidence interval): 1.047 (1.001;1.095), p = 0.044]. Prolonged need of vasopressors (≥ 48 h) was observed in 36% of patients without SDB, in 64% with CSA, and in 62% with OSA (p = 0.037). AHI was significantly associated with prolonged (≥ 48 h) need of vasopressors [OR (95% CI): 1.052 (1.002;1.104), p = 0.040], independent of any confounders.

CONCLUSIONS

SDB, particularly OSA, is associated with prolonged LOS after CABG, independent of known confounders. Prolonged LOS in patients with SDB may be due to increased postoperative hemodynamic instability due to any cause.

Changes in Body Mass Index and Late Postoperative Outcomes in Elderly Coronary Artery Bypass Grafting Patients: A Follow-up Study

The purpose of this study was to describe the extent to which late postoperative health outcomes vary as a function of change in body mass index (BMI) in persons 65 years of age undergoing elective coronary artery bypass grafting (CABG). The mean age of the 90 persons in the original sample was 72.27 (±4.85) years. At follow-up (x = 18.73,s = 2.56 months postsurgery), 90% (n = 79 alive,n = 2 deceased, proxy completed interview) were contacted; 73% (n = 59) completed the telephone interview; and 9% (n = 8) were alive but lost to follow-up. BMI (kg/m2) was calculated from self-reported weight at follow-up. Outcomes included the Physical Component Summary (PCS) scale of the SF-36 Health Survey and readmission data. Thex (s ) for BMI at preoperative, postoperative, postdischarge, and follow-up were 28.1 (4.9) kg/ m2 , 28.76 (4.9) kg/m2, 27.11 (4.8) kg/m2, and 27.95 (4.7) kg/m2, respectively. BMI changed over time,P < 0.05. Those who were readmitted lost more weight between preoperative and postdischarge than those who were not readmitted (x BMI = –2.26 vs.x BMI = –1.35),t = 2.17,df = 27.05,P = 0.04. Those who lost less weight between preoperative and postdischarge were less likely to be readmitted,.2 = 5.755 (1),P = 0.02, with 25% sensitivity and 92% specificity. Thex (sx) for PCS at preoperative, postdischarge, and follow-up were 36.93 (1.62), 35.72 (1.27), and 42.26 (1.45), respectively, reflecting change over time,F = 11.43 (2),P < 0.001. At follow-up, older elective CABG patients do not appear to regain weight lost between preoperative and postdischarge; however, self-reported physical health is improved. Also, initial weight loss is related to readmissions.

Evaluation of the influence of pulmonary hypertension in ultra-fast-track anesthesia technique in adult patients undergoing cardiac surgery

Objective

To evaluate the influence of pulmonary hypertension in the ultra-fast-track anesthesia technique in adult cardiac surgery.

Methods

A retrospective study. They were included 40 patients divided into two groups: GI (without pulmonary hypertension) and GII (with pulmonary hypertension). Based on data obtained by transthoracic echocardiography. We considered as the absence of pulmonary hypertension: a pulmonary artery systolic pressure (sPAP) <36 mmHg, with tricuspid regurgitation velocity <2.8 m/s and no additional echocardiographic signs of PH, and PH as presence: a sPAP >40 mmHg associated with additional echocardiographic signs of PH. It was established as influence of pulmonary hypertension: the impossibility of extubation in the operating room, the increase in the time interval for extubation and reintubation the first 24 hours postoperatively. Univariate and multivariate analyzes were performed when necessary. Considered significant a P value <0.05.

Results

The GI was composed of 21 patients and GII for 19. All patients (100%) were extubated in the operating room in a medium time interval of 17.58±8.06 min with a median of 18 min in GII and 17 min in GI. PH did not increase the time interval for extubation (P=0.397). It required reintubation of 2 patients in GII (5% of the total), without statistically significant as compared to GI (P=0.488).

Conclusion

In this study, pulmonary hypertension did not influence on ultra-fast-track anesthesia in adult cardiac surgery.

Preoperative frontal QRS-T angle is an independent correlate of hospital length of stay and predictor of haemodynamic support requirement following off-pump coronary artery bypass graft surgery

OBJECTIVES

With the adoption of novel operative techniques and aggressive care protocols that facilitate earlier extubation and mobilization of patients, postoperative length of stay (LOS) following coronary artery bypass graft surgery (CABG) has declined. However, there is paucity of information regarding preoperative electrocardiographic predictors of LOS following CABG. In this study, we investigated whether frontal QRS-T angle, which is an abnormal repolarization marker in prediction of various cardiovascular events, was an independent correlate of postoperative hospital LOS for off-pump CABG. Furthermore, we evaluated independent predictors of vasopressor agent/intra-aortic balloon pump (IABP) support requirement following off-pump CABG.

METHODS

In this observational study, 78 patients with stable angina, who were scheduled for elective coronary artery bypass surgery following diagnosis of obstructive coronary artery disease by conventional angiography, were enrolled.

RESULTS

Left ventricular ejection fraction (LVEF) was significantly lower and vasopressor agent/IABP support requirement and incidence of sustained atrial or ventricular arrhythmias was higher in patients with wide QRS-T angle (P < 0.05). Postoperative hospital LOS was also longer in this group. From the preoperative characteristics, wide frontal QRS-T angle was found to be an independent correlate of postoperative hospital LOS (B ± SD: 11.97 ± 0.62, P ≤ 0.01). Wide frontal QRS-T angle was also found to be an independent predictor of vasopressor agent/IABP support requirement postoperatively (OR: 7.87, P ≤ 0.01).

CONCLUSIONS

Prediction of the hospital LOS and patient outcome following CABG is of great importance. Being easily obtainable via standard 12-lead electrocardiogram and its low cost may make frontal QRS-T angle a beneficial marker for reducing both patient-based morbidity and economic burden.

Risk factor analysis for fast track protocol failure

BACKGROUND

The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.

METHODS

229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.

RESULTS

Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).

CONCLUSION

Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.

Epidural anesthesia improves outcome and resource use in cardiac surgery: a single-center study of a 1293-patient cohort

Thoracic epidural anesthesia (TEA) combined with general anesthesia in cardiac surgery has the potential to initiate earlier spontaneous ventilation and extubation, improved hemodynamics, less arrhythmia or myocardial ischemia, and an attenuated neurohormonal response. The aim of the current study was to characterize the correlation between TEA and postoperative resource use or outcome in a consecutive-patient cohort. The study was performed in a tertiary care, 3-surgeon, university-affiliated hospital that performs 350 to 400 cardiac surgeries per year. All 1293 adult patients who underwent cardiac surgery between July 1, 2002, and February 1, 2006, were included. Patients were assigned to anesthesiologists practicing TEA (TEA group, n = 506) or not (control group, n = 787) for cardiac surgery. The preoperative parameter values and Parsonnet scores for the 2 groups were similar. The 2 groups had the same distribution of surgery types. The TEA group presented with fewer intensive care unit (ICU) complications, such as delirium, pneumonia, and acute renal failure, and presented with better myocardial protection. The TEA group presented with a higher proportion of immediately postoperative extubations and with shorter ventilation times and ICU stays. Total ICU costs decreased from US $18,700 to $9900 per patient. Combining TEA and general anesthesia for cardiac surgery allows a significant change in anesthesia strategy. This change improves immediate postoperative outcomes and reduces the use and costs of ICU resources.

Feasibility of the fast-track recovery program after cardiac surgery in Japan

OBJECTIVES

The purpose of this study was to determine if a fast-track recovery protocol that is applied in other countries can be used in the present Japanese medical system. Second, we wanted to evaluate the differences if the protocol was adapted from the viewpoint of cost saving, postoperative hospital stay, and adverse complications.

METHODS

We retrospectively analyzed 94 consecutive patients who underwent cardiovascular surgery with conventional techniques on cardiac arrest requiring cardiopulmonary bypass between July 1, 2004 and June 30, 2006. We started our fast-track recovery protocol from July 1, 2005. We compared the results of the conventional group (before July 1, 2005) and the fast-track recovery protocol group (after July 1, 2005). Moreover, we used a unique questionnaire and investigated how the patients in the fast-track group felt about the short hospital stay postoperatively.

RESULTS

The mean postoperative hospital stay was 36.7 +/- 6.0 days for the conventional group and 15.0 +/- 12.4 days for the fast-track group, with a statistically significant difference (P = 0.01). The mean cost fell by almost half, from 712545 yen to 383268 yen (P = 0.038). The difference in complication rates was not statistically significant.

CONCLUSION

A fast-track recovery protocol can be safely adapted to patients in the Japanese system without increasing the mortality or morbidity rate. Based on our unique questionnaires, the most important factor was sufficient and repeated explanations preoperatively to the patients and their family members. Second, good pain control with routine use of acetaminophen and sporadic morphine orally has a great effect on the patients' recovery.

Trends in postoperative length of stay after bypass surgery

BACKGROUND

Although single-site studies have reported reductions in coronary artery bypass graft (CABG) surgery length of stay (LOS) over the last 15 years, less information is available regarding overall temporal trends and interhospital variability. This study examined trends in postoperative LOS, associated rates of transfer at discharge and variation among hospitals in LOS at CABG hospitals in New York State.

METHODS

Trends in postoperative LOS and transfers at discharge for 105,842 CABG patients treated in 30 hospitals in New York between 1992 and 1998 were first described graphically. Mixed models were then used to assess temporal trends and interhospital variability in LOS, accounting for differences in patient risk and within-hospital correlation in outcomes. Clinical and LOS data were obtained from the Cardiac Surgery Reporting System. Additional information was extracted from the New York Statewide Planning and Research Cooperative System.

RESULTS

Postoperative LOS decreased 30% between 1992 and 1998 after adjusting for patient risk. A concurrent increase in the probability of nonacute patient transfers occurred over time, with the most pronounced increase in patients with stays exceeding 5 days. Underlying the downward trend in LOS was substantial interhospital variability that peaked in 1994 and remained significant in 1998. Stays were longer at hospitals located in New York City.

CONCLUSIONS

The downward shift in LOS observed in the 1990s was achieved in part by an increase in nonacute care transfers, reflecting a shift in care setting. After decreasing trends in postoperative stays tapered off, significant variability among hospitals remained.

Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol

The development of less invasive methods for myocardial revascularization such as "off-pump" cardiac surgery, and new methods of anesthesia and postoperative care protocols such as "fast-track recovery" (FTRC), have contributed to a significant reduction in postoperative intensive care unit (ICU) and hospital length of stay after cardiac surgical procedures. The objectives of this study were to identify perioperative risk factors of prolonged hospital stay, hospital mortality, and readmission rates in off-pump coronary artery bypass surgery (CABG) patients undergoing the FTRC protocol. Eighty consecutive patients undergoing off-pump coronary artery bypass surgery with FTRC protocol were included in the study. For the first purpose of this protocol, early extubation is defined as removal of the endotracheal tube within 6 h of arrival at the surgical ICU. The second purpose was to obtain a minimal length of stay in the ICU (<24 h) and hospital discharge within 5 days. We analyzed the influence of the preoperative, intraoperative, and postoperative variables on prolonged hospital stay, hospital mortality, and hospital readmission. Three patients died during hospitalization, giving a hospital mortality rate of 3.75%. The causes of hospital death were massive stroke and sepsis. Using multivariate logistic regression analysis, hypertension (P = 0.0185), postoperative stroke (P = 0.0001), and sternal infection (P = 0.0007) were identified as independent predictors of hospital mortality. Mean hospital length of stay was 4.23 +/- 0.75 days. Univariate and multivariate logistic regression analysis revealed that postoperative blood use (P = 0.0095) was the major independent predictor of prolonged hospital stay. During the 30-day observation period, seven patients were readmitted. One of these patients died on postoperative day 45 from mediastinitis and sepsis. Multivariate logistic regression analysis identified age (P = 0.0033) and hypertension (P = 0.045) as independent predictors of hospital readmission. FTRC protocols can be performed safely in patients with off-pump CABG, and the mortality and readmission rates following this protocol were found to be within acceptable ranges.

Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery

OBJECTIVE

To compare patients undergoing valve surgery through a minithoracotomy approach with a matched group undergoing conventional valve surgery.

DESIGN

Control study.

SETTING

University hospital, single center.

PARTICIPANTS

Forty-one consecutive patients scheduled for valve surgery by minithoracotomy approach were matched with a similar group of patients operated on by the sternotomy approach.

INTERVENTIONS

Criteria for matching included type of valve procedure (aortic valve replacement or mitral valve repair), age, surgeons, and left ventricular function. Two surgeons performed the surgical procedures. Perioperative care was standardized for all patients. Operative and postoperative data were recorded.

MEASUREMENTS AND MAIN RESULTS

The 41 pairs of patients were correctly matched, except for left ventricular function (n = 1). Twenty patients underwent mitral valve repair and 62 aortic valve replacement. Preoperative demographic data and clinical characteristics were similar in both groups. Cardiopulmonary bypass, aortic clamping, and surgery times were longer in the minithoracotomy group (p < 0.05). In 3 patients, the minithoracotomy approach had to be converted into a sternotomy during the surgical procedure for better visualization. Minithoracotomy patients had significantly increased postoperative total blood loss (p < 0.05). No difference was found between the groups for extubation time and intensive care or in-hospital lengths of stay.

CONCLUSION

These results suggest that valve surgery is feasible in many cases through minithoracotomy. Nevertheless, this approach increases surgical complexity and in this comparative study no significant benefit was shown.

Changes in nutritional status and postoperative outcomes in elderly CABG patients

OBJECTIVES

To systematically examine the pattern of nutritional status over time in older people undergoing elective coronary artery bypass grafting (CABG) and the extent to which nutritional status affects health outcomes postdischarge.

DESIGN

The sample consisted of 91 community-dwelling English-speaking persons > or = 65 (72.27 +/- 4.85) years of age with normal cognitive function and no active cancer. Data collected prospectively at 3 time points (preoperatively, postoperatively on day 5, and 4 to 6 weeks postdischarge) included serum albumin, transferrin, and calculated Body Mass Index (BMI). The Short-Form 36 Health Status Survey Questionnaire was administered 4 to 6 weeks postdischarge as a primary health outcome measure.

RESULTS

Nutritional status changed over time. For albumin and transferrin, the pattern of change corresponded to the phases of surgical stress (P = 0.001). The BMI decreased from preoperative to 4 to 6 weeks postdischarge (P = 0.001), and this decrease explained 13.8% of the variance in physical health 4 to 6 weeks postdischarge (P = 0.008). The change in the BMI corresponds to an average weight loss of 5% from preoperative to postdischarge.

CONCLUSIONS

Older people undergoing CABG who lose significant weight from preoperative to postdischarge are more likely to have lower self-reported physical health.

Rapid recovery protocol applied to 5,658 consecutive "on-pump" coronary bypass patients

BACKGROUND

Increasing hospital costs, restricted resources, and new surgical strategies have stimulated effectiveness of all routines in cardiac surgery. Over a 10-year period, 5,658 consecutive patients undergoing coronary artery bypass grafting followed a protocol aiming at short postoperative intubation times and rapid physical rehabilitation.

METHODS

The patients were prepared for rapid recovery, emphasizing (1) preoperative education and respiratory training, (2) low-dose fentanyl anesthesia, (3) limited ischemic times and pump times, (4) mild hypothermia and rewarming to a rectal temperature of 36 degrees C, (5) restricted use of extended monitoring, (6) autologous blood salvage to avoid allogeneic blood transfusions, and (7) active physical training from postoperative day 1. All in-hospital data relevant to these steps were prospectively stored in a database.

RESULTS

The median extubation time after arrival in the intensive care unit was 1.5 hours (0 to 320 hours). More than 99% of the patients were extubated within 5 hours. Sixty-two patients (1.1%) were reintubated and ventilated for a median of 24 hours (1 to 430 hours), mostly due to resternotomy for bleeding or cardiopulmonary decompensation. In total, 5,594 patients (98.9%) were able to sit in a chair the first postoperative day. Within the fourth postoperative day, 82.5% were able to move freely in the hospital area and were in fact physically fit for hospital discharge. Allogeneic blood products were given to 3.9% of the patients. Twenty-three patients (0.41%) died in-hospital.

CONCLUSIONS

With the application of a protocol for rapid physical recovery in patients undergoing "on-pump" coronary artery bypass grafting, extubation within 1 to 2 hours was safe and feasible in most patients. After 5 hours, 99.3% of the patients were extubated, with a reintubation rate of 1.1%. More than 80% of the patients were fully physically mobile within 4 days after the operation.

The lack of benefit of tracheal extubation in the operating room after coronary artery bypass surgery

Although early tracheal extubation in cardiac anesthesia is safe and cost beneficial, questions still remain regarding how early after cardiac surgery patients should be tracheally extubated (TE). Our objective was to determine the effects on resource use if patients scheduled for coronary artery bypass grafting have TE in the operating room (OR). We studied 100 consecutive patients undergoing elective coronary artery bypass grafting, requiring extracorporeal circulation, and those eligible for a fast-track pathway. At the end of the procedure, the patients were evaluated for TE in the OR if they were hemodynamically stable, were without significant bleeding, and fulfilled clinical and blood gas analysis variables. Patients who did not meet the requirements had TE in the intensive care unit (ICU). Fifty patients had TE in the OR and 50 patients in the ICU. Time in the OR after skin closure, ICU length of stay, and postoperative length of stay were similar between the groups. Four patients (8%) in the OR group were tracheally reintubated secondary to respiratory depression (P = 0.11). Three patients (6%) in the OR group had postoperative myocardial infarction, and one postoperative myocardial infarction (2%) occurred in the ICU group (P = 0.61). All four patients recovered satisfactorily. The incidences of other complications were similar between groups.

The Economics of Cardiac Fast Tracking

Extubation within a few hours of cardiac surgery is possible in the majority of patients and is not associated with an increased risk for perioperative complications. Duration of intubation is an important factor in overall postoperative length of stay, and when early extubation is instituted as part of a comprehensive clinical pathway, it contributes to significant reductions in both intensive care unit and hospital length of stay. In association with reductions in direct variable costs, these reductions in length of stay have been shown in several studies to significantly reduce overall cost or charge.

A new cardiothoracic centre: 'how to do it?'

All cardiac surgical patients, emergency and routine, from the South West peninsula of England had to travel long distances until 19 months ago, a stressful if not dangerous situation. This paper describes the planning, commissioning and start-up of a brand new cardiac surgical facility. The lessons learnt may help similar projects as provision of specialist health care decentralizes.