Fast track as a routine for open heart surgery

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.

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.

Routine operation theatre extubation after cardiac surgery in the elderly

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.

Epidural analgesia for cardiac surgery

BACKGROUND

A combination of general anaesthesia (GA) with thoracic epidural analgesia (TEA) may have a beneficial effect on clinical outcomes by reducing the risk of perioperative complications after cardiac surgery.

OBJECTIVES

The objective of this review was to determine the impact of perioperative epidural analgesia in cardiac surgery on perioperative mortality and cardiac, pulmonary or neurological morbidity. We performed a meta-analysis to compare the risk of adverse events and mortality in patients undergoing cardiac surgery under general anaesthesia with and without epidural analgesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12) in The Cochrane Library; MEDLINE (PubMed) (1966 to November 2012); EMBASE (1989 to November 2012); CINHAL (1982 to November 2012) and the Science Citation Index (1988 to November 2012).

SELECTION CRITERIA

We included randomized controlled trials comparing outcomes in adult patients undergoing cardiac surgery with either GA alone or GA in combination with TEA.

DATA COLLECTION AND ANALYSIS

All publications found during the search were manually and independently reviewed by the two authors. We identified 5035 titles, of which 4990 studies did not satisfy the selection criteria or were duplicate publications, that were retrieved from the five different databases. We performed a full review on 45 studies, of which 31 publications met all inclusion criteria. These 31 publications reported on a total of 3047 patients, 1578 patients with GA and 1469 patients with GA plus TEA.

MAIN RESULTS

Through our search (November 2012) we have identified 5035 titles, of which 31 publications met our inclusion criteria and reported on a total of 3047 patients. Compared with GA alone, the pooled risk ratio (RR) for patients receiving GA with TEA showed an odds ratio (OR) of 0.84 (95% CI 0.33 to 2.13, 31 studies) for mortality; 0.76 (95% CI 0.49 to 1.19, 17 studies) for myocardial infarction; and 0.50 (95% CI 0.21 to 1.18, 10 studies) for stroke. The relative risks (RR) for respiratory complications and supraventricular arrhythmias were 0.68 (95% CI 0.54 to 0.86, 14 studies) and 0.65 (95% CI 0.50 to 0.86, 15 studies) respectively.

AUTHORS' CONCLUSIONS

This meta-analysis of studies, identified to 2010, showed that the use of TEA in patients undergoing coronary artery bypass graft surgery may reduce the risk of postoperative supraventricular arrhythmias and respiratory complications. There were no effects of TEA with GA on the risk of mortality, myocardial infarction or neurological complications compared with GA alone.

Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects

OBJECTIVE

This study was designed to assess the factors that influence immediate extubation following totally thoracoscopic closure of congenital heart defects.

SUBJECTS AND METHODS

Clinical and operational data of 216 patients (87 males, average age 13.6 ± 10.9 years) were retrospectively analyzed. Atrial (ASD, n = 90) or ventricular septal defects (VSD, n = 126) were closed via a totally thoracoscopic approach. Ultra-fast-track anesthesia (UFTA) was used in all patients.

RESULTS

Immediate extubation in the operating room was successfully performed in 156 (72.2%) patients. A delayed extubation was completed in the intensive care unit in the remaining 60 (27.8%) patients. There was no significant difference in the age, sex, body weight, or type of congenital heart defect between the immediate and delayed extubation groups (p > 0.05). However, more patients in the delayed extubation group had severe preoperational pulmonary hypertension [8 (13.3%) vs. 4 (2.3%), p < 0.05]. The cardiopulmonary bypass time, aortic clamp time, and total duration of the surgery in the immediate extubation group were shorter than in the delayed extubation group (p < 0.05). Multivariate logistic regression analysis showed that preoperational pulmonary hypertension, duration of the surgery or cardiopulmonary bypass, and dosage of fentanyl used during the surgery were independent predictors for immediate extubation.

CONCLUSIONS

UFTA and immediate extubation in the operating room was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of ASD or VSD. Preoperational pulmonary hypertension, duration of the surgery, and the dosage of fentanyl used for UFTA were the determining factors for immediate extubation.

Fast-track practice in cardiac surgery: results and predictors of outcome

OBJECTIVES

Various studies have shown different parameters as independent risk factors in predicting the success of fast-track postoperative management in cardiac surgery. In the present study, we evaluated our 7-year experience with the fast-track protocol and investigated the preoperative predictors of successful outcome.

METHODS

Between 2004 and 2010, 5367 consecutive patients undergoing cardiac surgery were preoperatively selected for postoperative admission in the postanaesthesia care unit (PACU) and were included in this study. These patients were then transferred to the ordinary ward on the same day of the operation. The primary end-point of the study was the success of the PACU protocol, defined as discharge to the ward on the same day, no further admission to the intensive care unit and no operative mortality. Logistic regression analysis was performed to detect the independent risk factors for failure of the PACU pathway.

RESULTS

Of 11,895 patients undergoing cardiac surgery, 5367 (45.2%) were postoperatively admitted to the PACU. The protocol was successful in 4510 patients (84.0%). Using the multivariate logistic regression analysis, older age and left ventricular dysfunction were found to be independent risk factors for failure of the PACU protocol [odds ratio of 0.98/year (0.97-0.98) and 0.31 (0.14-0.70), respectively].

CONCLUSIONS

Our fast-track management, called the PACU protocol, is efficient and safe for the postoperative management of selected patients undergoing cardiac surgery. Age and left ventricular dysfunction are significant preoperative predictors of failure of this protocol.

Pro: early extubation in the operating room following cardiac surgery in adults

There is growing evidence that the general current approach in many centers of continued mechanical ventilation following cardiac surgery has evolved through historical experience rather than having a strong physiological basis in current practice. There is evidence going back several decades supporting very early (in the operating room [OR]) extubation in pediatric cardiac anesthesia. The authors provide evidence from numerous sources showing that extubation in the OR or shortly after arrival in the ICU is safe and cost-effective and is not prevented by the type of cardiac surgery or the use of cardiopulmonary bypass. They query if the paradigm should not be reversed and very early extubation be the routine unless contraindicated. Like any anesthetic technique, appropriate patient selection is called for, but this technique is widely appropriate.

Prolonged ventilation post cardiac surgery--tips and pitfalls of the prediction game

Background

Few available models aim to identify patients at risk of prolonged ventilation after cardiac surgery. We compared prediction models developed in ICU in two adjacent periods of time, when significant changes were observed both in population characteristics and the perioperative management.

Methods

We performed a retrospective review of two cohorts of patients in our department in two subsequent time periods (July 2007 - December 2008, n = 2165; January 2009 - July 2010, n = 2192). The study was approved by the Institutional Ethics Committee and the individual patient consent was not required. Patients were divided with regard to ventilation time of more or less than 48 hours. Preoperative and procedure-related variables for prolonged ventilation were identified and multivariate logistic regression analysis was performed separately for each cohort.

Results

Most recent patients were older, with more co-morbidities, more frequently undergoing off-pump surgery. At the beginning of 2009 we also changed the technique of postoperative ventilation. Percentage of patients with prolonged ventilation decreased from 5.7% to 2.4% (p < 0.0001).Preoperative and procedure-related variables for prolonged ventilation were identified. Prediction models for prolonged ventilation were different for each cohort. Most recent significant predictors were: aortic aneurysm surgery (OR 12.9), emergency surgery (OR 5.3), combined procedures (OR 5.1), valve procedures (OR 3.2), preoperative renal dysfunction (OR 2.9) and preoperative stroke or TIA (OR 2.8).

Conclusions

Prediction models for postoperative ventilation should be regularly updated, particularly when major changes are noted in patients' demographics and surgical or anaesthetic technique.

Immediate extubation versus standard postoperative ventilation: Our experience in on pump open heart surgery

Elective postoperative ventilation in patients undergoing "on pump" open heart surgery has been a standard practice. Ultra fast-track extubation in the operating room is now an accepted technique for "off pump" coronary artery bypass grafting. We tried to incorporate these experiences in on pump open heart surgery and compare the haemodynamic and respiratory parameters in the immediate postoperative period, in patients on standard postoperative ventilation for 8-12 hours. After ethical committee's approval and informed consent were obtained, 72 patients, between 28 and 45 years of age, undergoing on pump open heart surgery, were selected for our study. We followed same standard anaesthetic, cardiopulmonary bypass (CPB) and cardioplegic protocol. Thirty-six patients (Group E) were randomly allocated for immediate extubation following operation, after fulfillment of standard extubation criteria. Those who failed to meet these criteria were not extubated and were excluded from the study. The remaining 36 patients (Group V) were electively ventilated and extubated after 8-12 hours. Standard monitoring for on pump open heart surgery, including bispectral index was done. The demographic data, surgical procedures, preoperative parameters, aortic cross clamp and cardiopulmonary bypass times were comparable in both the groups. Extubation was possible in more than 88% of cases (n=32 out of 36 cases) in Group E and none required reintubation for respiratory insufficiency. Respiratory, haemodynamic parameters and postoperative complications were comparable in both the groups in the postoperative period. Therefore, we can safely conclude that immediate extubation in the operating room after on pump open heart surgery is an alternative acceptable method to avoid postoperative ventilation and its related complications in selected patients.

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.

Influence of fast-track recovery after coronary artery bypass in the elderly

We retrospectively analyzed 711 consecutive patients who had isolated coronary artery bypass grafting between January 2000 and December 2004; 572 younger patients (< 70 years) were compared with 139 elderly patients (> or = 70 years). A rapid recovery program based on an anesthetic protocol for early extubation was applied to all patients. The overall hospital mortality rate was 3.3% for the younger group and 4.3% for the elderly group. There were no significant differences in rates of hospital mortality and postoperative complications between the two groups. Early extubation was achieved in significantly more younger (71%) compared to elderly (57%) patients. Rapid recovery with discharge before the 5(th) postoperative day was achieved in 19% of the elderly compared to 48% of the younger patients. Patients in the younger group were discharged from hospital earlier (6.8 +/- 0.3 vs 8.0 +/- 8.5 days). Application of fast-track treatment in an elderly population appears to be a safe and effective approach if used on a selective basis when criteria for early extubation are met.

Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

Background

Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems.

Methods

We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles.

Results

Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600).

Conclusion

These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.

Single dose parecoxib significantly improves ventilatory function in early extubation coronary artery bypass surgery: a prospective randomized double blind placebo controlled trial

BACKGROUND

Parecoxib, a cyclo oxygenase-2 inhibiting non-steroidal anti-inflammatory drug, has been widely used for postoperative analgesia. Our aim was to quantify the benefit of a single dose after coronary artery bypass grafting.

METHODS

The investigation was carried out as a randomized double blind placebo controlled study. A single i.v. dose of parecoxib 40 mg or placebo was given at closure of sternotomy. No opioid other than morphine was given in the first 24 postoperative hours. Pain was assessed using both a Visual Analogue Score (1-10), and the amount of morphine used via a morphine patient controlled analgesia pump. Creatinine clearance was measured before and after operation from 24 h urine collections. After a global announcement by Pfizer that paracoxib was 'contraindicated in patients with ischaemic heart disease' further recruitment was suspended and the collected data from 40 patients were analysed.

RESULTS

Twenty-one patients received parecoxib and 19 received placebo. Amongst those who received parecoxib, there was a highly significant sparing of rescue medication before tracheal extubation (P=0.004) compared with placebo, and an overall 35% morphine sparing effect during the first 6 h post extubation after correction for the variability in extubation time (P=0.037). Respiration, as measured by arterial carbon dioxide tension at the time of extubation, was significantly better in the parecoxib group (P=0.045). Significantly more furosemide was given for postoperative oliguria in those patients who received parecoxib (P=0.036). After correcting for differences in diuretic usage and fluid balance, parecoxib was associated with a significant increase in plasma creatinine (P=0.041).

CONCLUSION

A single dose of parecoxib has a significant opioid sparing effect in the first 6 h after coronary artery bypass grafting which resulted in significantly improved ventilation with mild elevation of plasma creatinine within normal limits.

Prolonged intubation rates after coronary artery bypass surgery and ICU risk stratification score

OBJECTIVE

To determine prolonged intubation rates among patients undergoing coronary artery bypass graft (CABG) surgery, and to evaluate the ability of the Intensive Care Unit Risk Stratification Score (ICURSS) model to predict these events.

DESIGN

Prospective observational study.

SETTING

A 24-bed ICU in a tertiary referral university hospital.

PATIENTS

Five hundred sixty-nine patients undergoing CABG surgery.

INTERVENTIONS

Variables of the ICURSS model were recorded at ICU admission. Extubation was performed according to a standard protocol. Patients remaining intubated within 8 h after ICU admission were designated as having early extubation failure (EEF). The next evaluations at 16, 24, 48, 72, and 96 h designated patients as having a prolonged intubation period (PIP) and prolonged mechanical ventilation (PMV) for 24, 48, 72, and 96 h. The ability of the ICURSS model to predict extubation failure at different cutoff values was measured using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating characteristic curve.

MEASUREMENTS AND RESULTS

Prolonged intubation rates were as follows: EEF, 40.2%; PIP, 17.2%; PMV for 24 h, 10.4%; PMV for 48 h, 7.6%; PMV for 72 h, 6.5%; and PMV for 96 h, 6.0%. At every cutoff, the ICURSS showed poor discrimination to predict the failure to be extubated. Calibration was also poor, although some ability to predict both EEF and PMV at > or = 48 h was shown.

CONCLUSIONS

Prolonged intubation rates after undergoing CABG surgery in our setting were comparable with those of other reports from institutions where fast-track cardiac anesthesia is currently in practice. In our cohort, the ICURSS was not useful for the prediction of length of intubation.

Thoracic epidural analgesia in coronary artery bypass graft surgery: seven years' experience

OBJECTIVE

To evaluate the risk of neurologic complications caused by an epidural hematoma in a series of patients who had coronary artery bypass graft surgery with cardiopulmonary bypass under combined general and thoracic epidural anesthesia (TEA).

DESIGN

Prospective observational study.

SETTING

General hospital associated with a university.

PARTICIPANTS

Seven hundred fourteen patients who had coronary artery bypass grafting surgery over a 7-year period.

INTERVENTIONS

An epidural catheter was inserted at T(1)-T(3) as soon as the patient was in the operating room and local anesthetic was administered as a bolus and then as a continuous infusion throughout the operation and postoperatively. A set of safety guidelines was routinely followed. A protocol for postoperative neurologic evaluation was used to rule out any signs of spinal compression.

MEASUREMENTS AND MAIN RESULTS

Preoperatively, a battery of coagulation tests was systematically performed including APTT, platelet count, and prothrombin time. Antiplatelet drugs (aspirin) were stopped at least 7 days before surgery. No patient required parenteral opiates postoperatively. Seventy-five percent of the patients were extubated in the operating room. No clinical epidural hematomas were detected.

CONCLUSION

In this study, some of the benefits previously reported during cardiac surgery under TEA, such as excellent analgesia and early extubation, were confirmed. In addition, the series adds further evidence that adherence to a set of standard safety measures, in this setting, averts the occurrence of symptomatic epidural hematomas.

[High thoracic epidural anesthesia in coronary surgery]

INTRODUCTION

High thoracic epidural anesthesia and analgesia are being increasingly used for coronary artery bypass graft surgery. The reasons for this include excellent perioperative pain control with advantage of early tracheal extubation, improved postoperative pulmonary function, and cardiac protection due to sympthatetic blockade.

EFFECTS OF HIGH THORACIC EPIDURAL ANESTHESIA

Cardiac protection is the consequence of decreased heart rate, myocardial contractility and arterial blood pressure, without changes in coronary perfusion pressure. Therefore, high thoracic epidural analgesia beneficially alters major determinants of myocardial oxygen consumption, without jeopardizing coronary perfusion pressure. In addition, decrease of functional residual capacity, may reduce postoperative pulmonary morbidity.

RESULTS OF CLINICAL STUDIES

Patients with high thoracic epidural anesthesia revealed a more favourable perioperative hemodynamic profile, lower incidence of ischemia and better response to perioperative stress.

HIGH THORACIC EPIDURAL ANESTHESIA TECHNIQUE

The epidural catheter should be placed at the Th2/Th3 interspace at least one hour before administration of heparin. After local anesthetic bolus dose, a continuous epidural infusion is recommended.

CONCLUSION

There is strong evidence for beneficial effects of high thoracic epidural anesthesia in patients undergoing surgical myocardial revascularization. However, it is still underutilized in current clinical practice.

[Combined general anesthesia and high thoracic epidural analgesia in myocardial revascularization of the failing heart in a patient on hemodialysis]

Terminal renal failure is often associated with severe coronary artery disease that should be treated with surgical myocardial revascularization. Since perioperative morbidity and mortality rates in these patients are high, the best way and the time for surgical intervention are still uncertain. We present the patient with end-stage renal disease, on chronic program of hemodialysis, who had underwent off-pump coronary artery bypass grafting and high thoracic epidural anaesthesia, followed by early extubation. To our knowledge, off-pump surgical myocardial revascularization in patients on hemodialysis using this anaesthetic technique has not yet been presented in our literature.

Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia

BACKGROUND

The expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia.

METHODS

Fast-track anesthesia using an ultra-shortacting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 microg x kg(-1) x min(-1)).

RESULTS

Operating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation.

CONCLUSIONS

Immediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising.