Change in anaesthesia practice and postoperative sedation shortens ICU and hospital length of stay following coronary artery bypass surgery

Fast tracking in cardiac surgery: is it safe?

Background

While fast track clinical pathways have been demonstrated to reduce resource utilization in patients undergoing cardiac surgery, it remains unclear as to whether they adversely affect post-operative outcomes. The purpose of this study was to determine the impact of fast tracking on post-operative outcomes following cardiac surgery.

Methods

In a retrospective study, all patients undergoing first-time, on-pump, non-emergent coronary artery bypass grafting, valve, or coronary artery bypass grafting + valve at a single centre between 2010 and 2017 were included. Patients were considered to have been fast tracked if they were extubated and transferred from intensive care to a step-down unit on the same day as their procedure. The risk-adjusted effect of fast tracking on a 30-day composite of all-cause mortality, stroke, renal failure, infection, atrial fibrillation, and readmission to hospital was determined. Furthermore, propensity score matching was used to match fasting track patients in a 1-to-1 manner with their nearest “neighbor” in the control group and subsequently compared in terms of 30-day post-operative outcomes.

Results

3252 patients formed the final study population (fast track: n = 245; control: n = 3007). Patients who were fast tracked experienced reduced time to initial extubation (4.3 vs. 5.6 h, p < 0.0001) and lower median initial intensive care unit length of stay (7.8 vs. 20.4 h, p < 0.0001). Fast tracked patients experienced lower 30-day rates of the composite outcome (42.4% vs. 51.5%, p = 0.008). However, following propensity score matching, fast tracked patients experienced similar 30-day rates of the composite outcome as the control group (42.4% vs. 44.5%, p = 0.72). After risk adjustment using multivariable regression modeling, fast tracking was predictive of an improved 30-day composite outcome (OR 0.75, 95% CI 0.57–0.98, p = 0.03).

Conclusion

Fast track clinical pathways was associated with reduced intensive care unit, overall length of stay and similar 30-day post-operative outcomes. These results suggest that fast tracking appropriate patients may reduce resource utilization, while maintaining patient safety.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01815-9.

A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients

PURPOSE

Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam.

METHODS

We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients).

RESULTS

Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes.

CONCLUSIONS

Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.

Early Extubation in Enhanced Recovery from Cardiac Surgery

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.

Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes

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.

Sedative drugs used for mechanically ventilated patients in intensive care units: a systematic review and network meta-analysis

BACKGROUND

The effects of different sedative drugs on all-cause mortality rate, duration of ICU stay, and risk of delirium in mechanically ventilated ICU patients are unclear. This meta-analysis aimed to compare the effectiveness and safety of individual sedative drugs and drug combinations in mechanically ventilated ICU patients.

MATERIALS AND METHODS

Medline, Embase, Cochrane, EBSCOhost, and ISI Web of Science databases were searched for studies that assessed sedation in ICU mechanically ventilated patients. A Bayesian random-effects model was used to combine the direct comparisons and indirect evidence.

RESULTS

Thirty-one randomized, controlled trials were included, which consisted of 4491 patients who received one of seven sedative drugs or a combination of drugs. There were no significant differences regarding the all-cause mortality rate. Compared to propofol, inhalation anesthetics (hazard ratio [HR] 0.121; 95% credible interval [CrI] -7.58 to 7.62), alpha agonists (HR 2.2; 95% CrI 0.776 to 5.22), propofol with benzodiazepines (HR 0.306; 95% CrI -6.97 to 7.65), ketamine with benzodiazepines (HR 6.57; 95% CrI -6.05 to 19.1) and placebo (HR 2.4; 95% CrI -5.37 to 10.3), benzodiazepines (HR 3.62; 95% CrI 0.834 to 6.2) may increase the duration of ICU stay. Compared to alpha agonists, propofol (HR 2.4; 95% CrI 0.304 to 21.1) and placebo (HR 6.12; 95% CrI 0.745 to 54.6), benzodiazepines (HR 2.59; 95% CrI 1.08 to 7.4) were associated with incremental risks of delirium.

CONCLUSION

Compared to propofol, benzodiazepines may increase the duration of ICU stay. Compared to alpha agonists, benzodiazepines were associated with an increased risk of delirium.

Propofol or benzodiazepines for short- and long-term sedation in intensive care units? An economic evaluation based on meta-analytic results

Purpose

This evaluation compares propofol and benzodiazepine sedation for mechanically ventilated patients in intensive care units (ICUs) in order to identify the potential economic benefits from different payers' perspectives.

Methods

The patient-level simulation model incorporated efficacy estimates from a structured meta-analysis and ICU-related costs from Italy, Germany, France, UK, and the USA. Efficacy outcomes were ICU length of stay (LOS), mechanical ventilation duration, and weaning time. We calculated ICU costs from mechanical ventilation duration and ICU LOS based on national average ICU costs with and without mechanical ventilation. Three scenarios were investigated: 1) long-term sedation >24 hours based on results from randomized controlled trials (RCTs); 2) long-term sedation based on RCT plus non-RCT results; and 3) short-term sedation <24 hours based on RCT results. We tested the model's robustness for input uncertainties by deterministic (DSA) and probabilistic sensitivity analyses (PSA).

Results

In the base case, mean savings with propofol versus benzodiazepines in long-term sedation ranged from €406 (95% confidence interval [CI]: 646 to 164) in Italy to 1,632 € (95% CI: 2,362 to 880) in the USA. Inclusion of non-RCT data corroborated these results. Savings in short-term sedation ranged from €148 (95% CI: 291 to 2) in Italy to €502 (95% CI: 936 to 57) in the USA. Parameters related to ICU and mechanical ventilation had a stronger influence in the DSA than drug-related parameters. In PSA, propofol reduced costs and ICU LOS compared to benzodiazepines in 94%-100% of simulations. The largest savings may be possible in the UK and the USA due to higher ICU costs.

Conclusion

Current ICU sedation guidelines recommend propofol rather than midazolam for mechanically ventilated patients. This evaluation endorses the recommendation as it may lead to better outcomes and savings for health care systems, especially in countries with higher ICU-related costs.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization

Objective

Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward.

Methods

In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics.

Results

Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days.

Conclusions

In patients undergoing robotic-assisted CABG, ultrafasttrack cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Examining Health Care Costs: Opportunities to Provide Value in the Intensive Care Unit

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.

Fast-track cardiac care for adult cardiac surgical patients

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.

Pulmonary Complications After Cardiac Surgery

Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.

Can the Cost of Distal Vascular Reconstruction be Reduced Without Sacrificing Quality? Analysis of 500 Cases

The goal of clinical pathways is to reduce the cost of the hospitalization while maintaining acceptable results (patency, morbidity, and mortality). Patients who present with lower extremity revascularization pose a difficult problem, for they have significant comorbid medical disease. In this study the authors analyze their results and the treatment cost for patients undergoing lower extremity revascularization before and after the institution of clinical pathways.

Data were collected independently by the hospital financial office, and surgical outcomes were derived from the prospectively collected computerized vascular registry. Data were analyzed for 12 months before and after institution of pathways. Cost, length of stay (LOS), and use of ancillary service as well as mortality, morbidity, and patency rates were evaluated. During each period, patients were selectively admitted to the intensive care unit based on perioperative risk factors independent of the pathway.

Three hundred ninety-nine patients with distal reconstructions were placed on the path during this time period. These were compared to a group of 286 patients who were not on the path in the year prior. The LOS decreased from 14.3 days to 9.2 days. Electrolyte laboratory panels decreased from 12 draws per patient per admission to two draws per patient per admission. This trend was also seen in complete blood count (11.8 to 6.8), glucose (12.6 to 2.1), and electrolytes (12.2 to 1.8). Perioperative mortality rates were similar (2.5% vs 1.9%) with no change in morbidity rates. Total cost for hospitalization decreased by 27% after institution of the clinical pathway.

From these data, the authors can demonstrate that the institution of clinical pathways not only decreased total cost, use of ancillary laboratory tests, and LOS but also did not negatively impact on outcome.

A Randomized Controlled Trial of Adaptive Support Ventilation Mode to Wean Patients after Fast-track Cardiac Valvular Surgery

Background:

Adaptive support ventilation can speed weaning after coronary artery surgery compared with protocolized weaning using other modes. There are no data to support this mode of weaning after cardiac valvular surgery. Furthermore, control group weaning times have been long, suggesting that the results may reflect control group protocols that delay weaning rather than a real advantage of adaptive support ventilation.

Methods:

Randomized (computer-generated sequence and sealed opaque envelopes), parallel-arm, unblinded trial of adaptive support ventilation versus physician-directed weaning after adult fast-track cardiac valvular surgery. The primary outcome was duration of mechanical ventilation. Patients aged 18 to 80 yr without significant renal, liver, or lung disease or severe impairment of left ventricular function undergoing uncomplicated elective valve surgery were eligible. Care was standardized, except postoperative ventilation. In the adaptive support ventilation group, target minute ventilation and inspired oxygen concentration were adjusted according to blood gases. A spontaneous breathing trial was carried out when the total inspiratory pressure of 15 cm H2O or less with positive end-expiratory pressure of 5 cm H2O. In the control group, the duty physician made all ventilatory decisions.

Results:

Median duration of ventilation was statistically significantly shorter (P = 0.013) in the adaptive support ventilation group (205 [141 to 295] min, n = 30) than that in controls (342 [214 to 491] min, n = 31). Manual ventilator changes and alarms were less common in the adaptive support ventilation group, and arterial blood gas estimations were more common.

Conclusion:

Adaptive support ventilation reduces ventilation time by more than 2 h in patients who have undergone fast-track cardiac valvular surgery while reducing the number of manual ventilator changes and alarms.

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the 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 published in 2003.

OBJECTIVES

To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

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 were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the 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 the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI).

MAIN RESULTS

Twenty-five trials involving 4118 patients were included in the review. There were two studies with a low risk of bias and nine studies with a high risk of bias. There were no differences in the risk of mortality within the first year after surgery between low-dose versus high-dose opioid based general anaesthesia groups (RR 0.58, 95% CI 0.28 to 1.18) and between early extubation protocol versus usual care groups (RR 0.84, 95% CI 0.40 to 1.75).There were no significant differences between low-dose versus high-dose opioid based anaesthesia groups for postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99), reintubation (RR 1.77, 95% CI 0.38 to 8.27), acute renal failure (RR 1.19, 95% CI 0.33 to 4.33), major bleeding (RR 0.48, 95% CI 0.16 to 1.44), and stroke (RR 1.17, 95% CI 0.36 to 3.78). Compared to the usual care, there were no significant differences in the risk of postoperative complications associated with early extubation: myocardial infarction (RR 0.94, 95% CI 0.55 to 1.60), reintubation (RR 1.91, 95% CI 0.90 to 4.07), acute renal failure (RR 0.77, 95% CI 0.19 to 3.10), major bleeding (RR 0.80, 95% CI 0.45 to 1.44), stroke (RR 0.87, 95% CI 0.31 to 2.46), major sepsis (RR 1.25, 95% CI 0.08 to 19.75) and wound infection (RR 0.67, 95% CI 0.25 to 1.83).Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital. One high quality cost-effectiveness analysis included in a randomized controlled trial showed that early extubation was likely to be cost-effective.

AUTHORS' CONCLUSIONS

The use of low-dose opioid based general anaesthesia and time-directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk. These fast-track interventions reduced the time to extubation and shortened the length of stay in the intensive care unit, but did not reduce the length of stay in the hospital.

Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation

AIM

This paper is a report of an investigation of the development, implementation and outcomes of a clinical guideline for nurse-led early extubation of adult coronary artery bypass graft patients.

BACKGROUND

Healthcare knowledge translation and utilization is an emerging but under-developed research area. The complex context for guideline development and use is methodologically challenging for robust and rigorous evaluation. This study contributes one such evaluation.

METHODS

This was a mixed methods evaluation, with a dominant quantitative study with a secondary qualitative study in a single UK cardiac surgery centre. An interrupted time series study (N = 567 elective coronary artery bypass graft patients) with concurrent within person controls was used to measure the impact of the guideline on the primary outcome: time to extubation. Semi-structured interviews with 11 clinical staff, informed by applied practitioner ethnography, explored the process of guideline development and implementation. The data were collected between January 2001 and January 2003.

RESULTS

There was no change in the interrupted time series study primary outcome as a consequence of the guideline implementation. The qualitative study identified three themes: context, process and tensions highlighting that the guideline did not require clinicians to change their practice, although it may have helped maintain practice through its educative role.

CONCLUSION

Further investigation and development of appropriate methods to capture the dynamism in healthcare contexts and its impact on guideline implementation seems warranted. Multi-site mixed methods investigations and programmes of research exploring knowledge translation and utilization initiatives, such as guideline implementation, are needed.

Light vs. heavy sedation during mechanical ventilation after oesophagectomy--a pilot experimental study focusing on memory

BACKGROUND

To assess and compare the feasibility and stressful memories of light vs. heavy sedation during post-operative mechanical ventilation.

METHODS

Randomized clinical trial in one general intensive care unit (ICU) in a Swedish university hospital. Thirty-six adults were randomly assigned to receive either light [Motor Activity Assessment Scale (MAAS) 3-4] or heavy (MAAS 1-2) sedation with continuous i.v. infusion of propofol during post-operative invasive mechanical ventilation after oesophagectomy. The patients were interviewed at the general ward 5 days post-ICU using the ICU Memory Tool and the ICU Stressful Experience Questionnaire, and 2 months post-ICU using the Impact of Event Scale Revised. Patient data and hourly recorded MAAS values were collected after the interviews.

RESULTS

Seventy-four per cent of the 139 MAAS values in the light sedation group (n=18) and 79% of the 142 in the heavy sedation group (n=18) were within the targeted levels, and the median MAAS scores were 3.0 vs. 1.25, respectively. Intention-to-treat analyses showed no significant difference in the prevalence of stressful memories between groups, including endotracheal tube discomfort, presenting wide 95% confidence intervals for the difference in outcome estimates. Excluding the patients with a prolonged ICU stay (n=3), a higher prevalence of delusional memories was found in the heavy sedation group (31% vs. 0%, P=0.04).

CONCLUSIONS

This small randomized-controlled pilot study suggests that a light sedation regimen during short-term post-operative mechanical ventilation after major surgery is feasible without increasing patient discomfort.

Indicators of Functional Deficits After Coronary Artery Bypass Surgery

The purposes of this study were to determine if ratings of difficulty or pain were more likely to detect deficits in activities of daily living (ADL) than degree of dependency and to longitudinally examine ADL in patients recovering from coronary artery bypass (CAB) surgery. This study included 40 patients who had recently undergone CAB surgery. We evaluated ADL performance using 3 subcategories of the Functional Status Index: mobility, personal care, and hand activities. Subjects completed the Functional Index before, 2 weeks after, and 2 months after CAB surgery. The percent of participants reporting difficulty or pain on the FSI was greater than the percent needing assistance except for hand activities preoperatively. Up to 65% of study participants reported deficits in ADL performance. In conclusion, assessments of ADL abilities that rely only on need for assistance may underestimate the presence of functional deficits in patients recovering from CAB surgery. Understanding functional level will assist in determining patient's need for rehabilitation services after CAB surgery.

Functional status of patients during subacute recovery from coronary artery bypass surgery

BACKGROUND

Patients recovering from coronary artery bypass (CAB) surgery are particularly vulnerable to impaired functional status because in addition to the direct effects of heart disease on cardiac performance, many surgical factors may contribute to loss of function.

OBJECTIVES

The purposes of this study were to describe functional status across multiple domains using performance-based and self-report assessments and to determine the relationship among different domains of functional status in patients recovering subacutely (<6 months) from CAB surgery.

METHODS

The participants in this study (n = 25) had undergone CAB surgery in the past 6 months. This cross-sectional descriptive study measured functional status in several domains using self-report and performance-based assessments.

RESULTS

The study results indicate that participants had deficits in health-related quality of life, activities of daily living performance, endurance/aerobic capacity, and cognitive/memory ability. Several correlations between the scores for outcome measures in different domains were found in this study.

CONCLUSIONS

Impaired functional status occurs in patients recovering subacutely from CAB surgery. Different aspects of functional status are related, and an understanding of these relationships may help to improve the medical management of patients after CAB surgery.

Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials*

OBJECTIVE

Evaluation of randomized, controlled clinical trials studying fast-track treatment in low-risk coronary artery bypass grafting patients.

DESIGN

Meta-regression.

PATIENTS

Low-risk coronary artery bypass grafting patients.

INTERVENTIONS

Fast-track treatments including (high or low) anesthetic dose, normothermia vs. hypothermia, and extubation protocol (within or after 8 hrs).

MEASUREMENTS

Number of hours of intensive care unit stay, number of days of hospital stay, prevalence of myocardial infarction, and death. Furthermore, quality of life and cost evaluations were evaluated. The epidemiologic and economic qualities of the different trials were also assessed.

MAIN RESULTS

A total of 27 studies evaluating fast-track treatment were identified, of which 12 studies were with major and 15 were without major differences in extubation protocol or anesthetic treatment or both. The use of an early extubation protocol (p=.000) but not the use of a low anesthetic dose (p=.394) or normothermic temperature management (p=.552) resulted in a decrease of the total intensive care unit stay of low-risk coronary artery bypass grafting patients. Early extubation was found to be an important determinant of the total hospital stay for these patients. An influence of the type of fast-track treatment on mortality or the prevalence of postoperative myocardial infarction was not observed. In general, the epidemiologic and economic qualities of included studies were moderate.

CONCLUSIONS

Although fast-track anesthetics and normothermic temperature management facilitate early extubation, the introduction of an early extubation protocol seems essential to decrease intensive care unit and hospital stay in low-risk coronary artery bypass grafting patients.

Short-stay intensive care after coronary artery bypass surgery: Randomized clinical trial on safety and cost-effectiveness*

OBJECTIVE

To evaluate the safety and cost-effectiveness of short-stay intensive care (SSIC) treatment for low-risk coronary artery bypass patients.

DESIGN

Randomized clinical equivalence trial.

SETTING

University Hospital Maastricht, the Netherlands.

PATIENTS

Low-risk coronary artery bypass patients.

INTERVENTIONS

A total of 600 patients were randomly assigned to undergo either SSIC treatment (8 hrs of intensive care treatment) or control treatment (care as usual, overnight intensive care treatment).

MEASUREMENTS

The primary outcome measures were intensive care readmissions and total hospital stay. The secondary outcome measures were total hospital costs, quality of life, postoperative morbidity, and mortality. Hospital costs consisted of the cost of hospital admission or admissions and outpatient costs.

MAIN RESULTS

The difference in intensive care readmission between the two groups of 1.13% was very small and not significantly different (p = .241; 95% confidence interval, -0.9% to 2.9%). The total hospital stay (p = .807; 95% confidence interval, 1.2 to -0.4) and postoperative morbidity were comparable between the groups. The SSIC group's quality of life improved more compared with the control group's quality of life (p = .0238; 95% confidence interval, 0.0012 to 0.0464). The total hospital costs for SSIC were significantly lower (95% confidence interval, -1,581 to -174) compared with those for the control group (4,625 and 5,441, respectively). The estimated incremental cost-effectiveness ratio (cost/delta quality-adjusted life months) thus showed the dominance of SSIC. Bootstrap and sensitivity analyses confirm the robustness of the study findings.

CONCLUSIONS

Compared with usual care, SSIC is a safe and cost-effective approach. SSIC can be considered as an alternative for conventional postoperative intensive care treatment for low-risk coronary artery bypass graft patients.

The enhanced postoperative care system

The perioperative care system is a continuum that includes preoperative patient evaluation, operating room scheduling, the operation itself, and postoperative care. This costly fast-paced system requires its various components to function efficiently and interact effectively. This review explores the interrelation between the operational elements of the enhanced care postoperative care system (intensive care units, intermediate care units, postanesthesia care units, and monitored floor beds) and other perioperative care activities. This care system provides patients with enhanced (from routine floor) nursing and medical care, continuous physiological monitoring, and sophisticated treatments (eg, continuous infusion of vasoactive substances). A management, rather than clinical, approach is used to provide insight into the operations of the perioperative care system so that bottlenecks to patient flow may be identified and eliminated. Emphasis is placed on the need to switch from a "fiefdom" mentality, where each component of the system acts independently and defensively, to systems thinking, in which complex interrelated patterns are identified, analyzed, and optimized.

Routine Immediate Extubation After Off-Pump Coronary Artery Bypass Surgery: 514 Consecutive Patients

OBJECTIVE

The purpose of this study was to evaluate the feasibility of routine immediate extubation in patients undergoing off-pump coronary artery bypass surgery.

DESIGN

Case series.

SETTING

Private hospital.

PARTICIPANTS

Five hundred forty-eight consecutive patients undergoing off-pump coronary bypass surgery, representing 5 years of a single anesthesiologist's practice, were evaluated for routine immediate extubation. Thirty-four patients were excluded because they were already intubated, in preoperative cardiogenic shock, or converted to on-pump during the procedure.

INTERVENTION

Patients received general anesthesia or general anesthesia plus thoracic epidural analgesia (25%) and underwent off-pump coronary bypass surgery.

MEASUREMENTS AND MAIN RESULTS

All 514 patients who were intended to be immediately extubated were expeditiously extubated in the operating room. The numbers of reintubations, morbidity, and mortality were low.

CONCLUSIONS

Routine immediate extubation of most off-pump coronary artery bypass patients appears feasible and most probably safe.

Outcomes of early extubation after bypass surgery in the elderly

BACKGROUND

While early extubation after coronary artery bypass grafting (CABG) has been associated with resource savings, its effect on patient outcomes remains unclear. The goal of the present investigation was to evaluate whether early extubation can be performed safely in elderly CABG patients in community practice.

METHODS

We studied 6,446 CABG patients, aged 65 years and older, treated at 35 hospitals between 1995 and 1998. Patients were categorized based on their post-CABG extubation duration (early, < 6 hours; intermediate, 6 to < 12 hours; and late, 12 to 24 hours). We compared unadjusted and risk-adjusted mortality, reintubation rates, and post-CABG length of stay (pLOS). We also examined the association between patients' intubation time and outcomes among patients with similar propensity for early extubation and among high-risk patient subgroups.

RESULTS

The overall mean post-CABG intubation time was 9.8 (SD 5.7) hours with 29% of patients extubated within 6 hours. After adjusting for preoperative risk factors patients extubated in less than 6 hours had significantly shorter postoperative hospital stays than those with later extubation times. Patients extubated early also tended to have equal or better risk-adjusted mortality than those with intermediate (odds ratio: 1.69, p = 0.08) or long intubation times (odds ratio: 1.97, p = 0.02). These results were consistent among patients with similar preoperative propensity for early extubation and among important high-risk patient subgroups. There was no evidence for higher reintubation rates among elderly patients selected for early extubation.

CONCLUSIONS

In community practice, early extubation after CABG can be achieved safely in selected elderly patients. This practice was associated with shorter hospital stays without adverse impact on postoperative outcomes.

Readmission to the intensive care unit after "fast-track" cardiac surgery: risk factors and outcomes

BACKGROUND

The introduction of "fast-track" management into cardiac surgery has significantly shortened the intensive care unit (ICU) length of stay. Readmission to the ICU, traditionally used as a quality index, has not been investigated in these patients. The aim of this study was to assess the causes, risk factors, and outcomes associated with readmission to the ICU.

METHODS

All patients undergoing open-heart surgery in a tertiary care, university-affiliated center were included in this prospective observational study. Preoperative and intraoperative data as well as ICU outcome were noted in all patients.

RESULTS

Over the 27-month study period,1,613 patients were targeted for fast track management (discharge from ICU on the first postoperative day). The readmission rate was 3.29% (53 patients). Forty-three percent of readmissions occurred within 24 hours of discharge usually because of pulmonary problems (43%) or arrhythmias (13%). Readmission was associated with a prolonged ICU stay (105 +/- 180.0 versus 19.2 +/- 2.4 hours of initial ICU stay) and worse outcome: the only patients who died (6 of 53, 11.3%) were in this group. On multivariate analysis, a Bernstein-Parsonnet risk estimate more than 20 strongly predicted readmission (odds ratio, 3.08; 95% confidence interval, 1.43 to 6.69).

CONCLUSIONS

Among a homogeneous group of patients targeted for fast-track management after cardiac surgery, readmission although uncommon is associated with a longer second ICU stay and significant mortality. The recognition of specific risk factors may allow for appropriate modification of the postoperative course.

Early extubation for adult cardiac surgical patients

BACKGROUND

Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays.

OBJECTIVES

To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL)(issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE(January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted.

MAIN RESULTS

Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively).

REVIEWER'S CONCLUSIONS

There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups. Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.

Trials comparing early vs late extubation following cardiovascular surgery

We identified 10 randomized trials that compared alternative management approaches to patient care during and following cardiovascular surgery. One overall strategy involved a modification of anesthesia, in particular, a reduction in the dosage of fentanyl and benzodiazepine or the substitution of fentanyl for propofol (five randomized controlled trials [RCTs]). Pooled results show a shorter duration of ventilation (7 h) and a shorter duration of hospital stay (approximately 1 day) associated with lower anesthetic doses. The second strategy involved early vs late extubation once patients were admitted to the ICU (five RCTs). Pooled results show a shorter duration of ventilation (13 h) and a shorter duration of ICU stay (half a day) associated with early extubation. An additional 8 nonrandomized trials had findings that were consistent with the 10 RCTs. Reintubation, complications, and mortality rates were too low to draw conclusions about these outcomes. Overall, these studies indicate that anesthetic, sedation, and early-extubation strategies in selected cardiac surgery patients are associated with a shorter duration of mechanical ventilation and shorter lengths of ICU and hospital stays.