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Stock S, Berger Veith S, Holst T, Erfani S, Pochert J, Dumps C, Girdauskas E. Feasibility of deescalating postoperative care in enhanced recovery after cardiac surgery. Front Cardiovasc Med 2024; 11:1412869. [PMID: 39188324 PMCID: PMC11345171 DOI: 10.3389/fcvm.2024.1412869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/29/2024] [Indexed: 08/28/2024] Open
Abstract
Introduction Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring. Methods 358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU). Results Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery (n = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement (n = 79) and aortic surgery (n = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU. Conclusions If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sarah Berger Veith
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Theresa Holst
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sahab Erfani
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Julia Pochert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Dumps
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
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Haunschild J, van Kampen A, Misfeld M, Von Aspern K, Ender J, Zakhary W, Borger MA, Etz CD. Is perioperative fast-track management the future of proximal aortic repair? EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6947988. [PMID: 36538944 DOI: 10.1093/ejcts/ezac578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 02/11/2023]
Abstract
OBJECTIVES The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Antonia van Kampen
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Martin Misfeld
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Institute of Academic Surgery, RPAH, Sydney, NSW, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | | | - Jörg Ender
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Waseem Zakhary
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Yiğit H, Demir ZA, Balcı E, Mavioğlu LH. Non-interventional Feasibility Assessment for Fast-Track Cardiac Anesthesia. Cureus 2023; 15:e34392. [PMID: 36874645 PMCID: PMC9976947 DOI: 10.7759/cureus.34392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/31/2023] Open
Abstract
Background The introduction of fast-track extubation procedures following cardiac surgery has significantly shortened hospitalization duration in intensive care units (ICUs). Early extubation is the most crucial step in getting out of the ICU early and providing ideal patient circulation. In times of crisis such as pandemics, it is vital to provide rapid flow through the hospital to prevent the postponement or inability to operate on patients awaiting surgery. This study aimed to determine the obstacles to early extubation in patients undergoing cardiac surgery and the perioperative characteristics that were affected in terms of fast-track extubation. Methodology This was an observational, cross-sectional study with data collected prospectively from October 1 to November 30, 2021. Preoperative data and comorbidities were recorded. Intraoperative and postoperative data were recorded and analyzed. Intraoperative cross-clamp duration, cardiopulmonary bypass duration, length of operation, and erythrocytes (red blood cells) transfused were recorded for each patient. Early postoperative clinical conditions were defined in patients whose mechanical ventilation duration exceeded eight hours (such as pulmonary complications, cardiovascular complications, renal complications, neurological conditions, and infective complications ). The length of ICU stay (hours), length of hospital stay (days), return to the ICU, reasons for return to the ICU, and overall hospital mortality were investigated. A total of 226 patients were included in the study. Patients were divided into two groups: extubated within eight hours (FTCA, fast-track cardiac anesthesia) and late extubation (after eight hours) postoperatively, and the data were evaluated accordingly. Results While 138 (61.1%) of the patients were extubated in eight hours or less, 88 (38.9%) patients were extubated after more than eight hours. The most common complications (55.7%) in patients with late extubation were cardiovascular complications, followed by respiratory complications (15.9%), and the surgeon's refusal (15.9%). In the logistic model created with the independent variables affecting the extubation time, the American Society of Anesthesiologists score and red blood cell transfusion were risk factors for longer extubation time. Conclusions In our research to reveal the feasibility of and barriers to FTCA, it was found that cardiac and respiratory problems were the most common reasons for delayed extubation. Due to the refusal of the surgical team, it was observed that some patients remained intubated despite meeting the FTCA requirements. It was considered the most improvable obstacle. Regarding cardiovascular complications, the team should aim to optimally control patient comorbidities in the preoperative period, reduce the use of red blood cell transfusions, and ensure that the entire team is updated on current extubation protocols, in particular surgeons and anesthesiologists.
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Affiliation(s)
- Hülya Yiğit
- Anesthesiology, Ankara City Hospital, Ankara, TUR
| | | | - Eda Balcı
- Anesthesiology, Ankara City Hospital, Ankara, TUR
| | - Levent H Mavioğlu
- Cardiac/Thoracic/Vascular Surgery, Ankara City Hospital, Ankara, TUR
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Van Praet KM, Kofler M, Hirsch S, Akansel S, Hommel M, Sündermann SH, Meyer A, Jacobs S, Falk V, Kempfert J. Factors associated with an unsuccessful Fast-Track course following Minimally Invasive Surgical Mitral Valve Repair. Eur J Cardiothorac Surg 2022; 62:6693624. [PMID: 36069638 DOI: 10.1093/ejcts/ezac451] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Analyses of fast-track processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery. METHODS Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of fast-track failure consisted of > 10 hours mechanical ventilation, >24 hours intensive care unit stay, re-intubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with fast-track failure. RESULTS In total, 491 patients were included in the study and were analysed. Two-hundred and thirty-seven patients (48.3%) failed the fast-track protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥3 (OR 2.05; CI 1.38-3.08; p < 0.001, pre-existing chronic kidney disease (OR 2.03; CI 1.14-3.70; p = 0.018), coronary artery disease (OR 1.90; CI 1.13-3.23; p = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; CI 2.81-36.01; p < 0.001) and procedure time (OR 1.01; CI 1.01-1.01; p < 0.001) were independently associated with fast-track failure. CONCLUSIONS Factors associated with fast-track failure in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed fast-track. CLINICAL REGISTRATION NUMBER The corresponding local ethics committee (Charité Medical School, Berlin, Germany) approved the present study which complies with the Declaration of Helsinki (ethics approval number: EA2/175/20).
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Affiliation(s)
- Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Solveig Hirsch
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Serdar Akansel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matthias Hommel
- Institute for Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
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Hendrikx J, Timmers M, AlTmimi L, Hoogma DF, De Coster J, Fieuws S, Herijgers P, Rega F, Verbrugghe P, Rex S. Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up. J Cardiothorac Vasc Anesth 2021; 36:2463-2472. [PMID: 35031218 DOI: 10.1053/j.jvca.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/25/2021] [Accepted: 12/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. DESIGN A retrospective cohort study. SETTING A single academic center. PARTICIPANTS Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. INTERVENTION The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. MEASUREMENTS AND MAIN RESULTS Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve = 0.676; 95% confidence interval, 0.611-0.741). CONCLUSION Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.
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Affiliation(s)
- Jore Hendrikx
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Maxim Timmers
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Layth AlTmimi
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Danny F Hoogma
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan De Coster
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Paul Herijgers
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
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Grützner H, Flo Forner A, Meineri M, Janai A, Ender J, Zakhary WZA. A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol. J Clin Med 2021; 10:jcm10194470. [PMID: 34640488 PMCID: PMC8509448 DOI: 10.3390/jcm10194470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/18/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022] Open
Abstract
The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55-120) min vs. off-pump 80 (55-120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.
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Affiliation(s)
- Henrike Grützner
- Section for Pediatrics and Youth Medicine, Public Health Department, Leipzig City Government, Friedrich-Ebert-Straße 19 a, 04109 Leipzig, Germany;
| | - Anna Flo Forner
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany; (A.F.F.); (M.M.); (A.J.); (J.E.)
| | - Massimiliano Meineri
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany; (A.F.F.); (M.M.); (A.J.); (J.E.)
| | - Aniruddha Janai
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany; (A.F.F.); (M.M.); (A.J.); (J.E.)
| | - Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany; (A.F.F.); (M.M.); (A.J.); (J.E.)
| | - Waseem Zakaria Aziz Zakhary
- Department of Anesthesiology and Intensive Care Medicine, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany; (A.F.F.); (M.M.); (A.J.); (J.E.)
- Correspondence:
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Bhavsar R, Jakobsen CJ. The Major Decrease in Resource Utilization in Recent Decades Seems Guided by Demographic Changes: Fast Tracking-Real Concept or Demographics. J Cardiothorac Vasc Anesth 2019; 34:1476-1484. [PMID: 31679999 DOI: 10.1053/j.jvca.2019.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/21/2019] [Accepted: 09/25/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify dynamics of associations and potential areas for optimization of patient turnover between various patient profile and comorbidity indicators and selected system performance indicators such as ventilation time, length of stay in the intensive care unit, and in-hospital stay. DESIGN Retrospective study of prospectively registered data (2000-2017). SETTING Three university hospitals. PARTICIPANTS The study comprised 38,100 adult cardiac surgical patients registered in the Western Denmark Heart Registry. INTERVENTIONS Analysis of dynamics in patient indicators and system performance indicators, including effect on the selected performance parameters. MEASUREMENTS AND MAIN RESULTS Comorbidity, calculated from EuroSCORE, decreased from 2.5 ± 2.2 to 1.5 ± 2.0 (p < 0.001), whereas the average age of patients increased from 65.1 ± 9.9 years to 67.6 ± 10.8 years (p < 0.001). Median ventilation time decreased from 380 to 275 minutes (p < 0.0001). The mean length of stay in the intensive care unit demonstrated a statistically significant decrease from 35.1 hours between 2000 to 2002 to 31.8 hours between 2015 to 2017 (p = 0.004), and the median time was unchanged at 22.0 hours throughout the observation period. The median in-hospital stay decreased from 6.5 to 5.1 days (p < 0.001) and the mean in-hospital stay from 8.7 days (2003-2005) to 7.0 days (2015-2017; p < 0.001). Logistic regression analysis of performance factors showed a statistically significant negative independent effect on most comorbidity and surgical factors. CONCLUSION The increase in performance parameters appears to be highly associated with decreased comorbidities and fast-tracking protocols and may only offer limited effect in additional patient turnover.
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Affiliation(s)
- Rajesh Bhavsar
- Surgery and Intensive Care East, Aarhus University Hospital, Aarhus, Denmark
| | - Carl-Johan Jakobsen
- Surgery and Intensive Care East, Aarhus University Hospital, Aarhus, Denmark.
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Sultan OW, Boland LL, Kinzy TG, Melamed RR, Seatter SC, Farivar RS, Kirkland LL, Mulder M. Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients. Am J Med Qual 2018; 33:576-582. [PMID: 29590756 DOI: 10.1177/1062860618766614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.
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Bouabdallaoui N, Stevens SR, Doenst T, Wrobel K, Bouchard D, Deja MA, Michler RE, Chua YL, Kalil RAK, Selzman CH, Daly RC, Sun B, Djokovic LT, Sopko G, Velazquez EJ, Rouleau JL, Lee KL, Al-Khalidi HR. Impact of Intubation Time on Survival following Coronary Artery Bypass Grafting: Insights from the Surgical Treatment for Ischemic Heart Failure (STICH) Trial. J Cardiothorac Vasc Anesth 2018; 32:1256-1263. [PMID: 29422280 DOI: 10.1053/j.jvca.2017.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to assess determinants of intubation time and evaluate its impact on 30-day and 1-year postoperative survival in Surgical Treatment for Ischemic Heart Failure (STICH) trial patients. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS A multivariable Cox proportional hazards model was used among the 1,446 surgical patients from the STICH trial who survived 36 hours after operation, in order to identify perioperative factors associated with 30-day and 1-year postoperative mortality. A multivariable logistic regression model was used to determine risk factors associated with intubation time. MEASUREMENTS AND MAIN RESULTS At 36 hours post-operation, 1,298 (out of 1,446) were extubated and 148 (10.2%) still intubated. Median postoperative intubation time was 11.4 hours. Among patients surviving 36 hours, a multivariable model was developed to predict 30-day (c-index = 0.88) and 1-year (c-index = 0.78) mortality. Intubation time was the strongest independent predictor of 30-day (hazard ratio [HR] 5.50) and 1-year mortality (HR 3.69). Predictors of intubation time >36 hours included mitral valve procedure, New York Heart Association class, left ventricular systolic volume index, creatinine, previous coronary artery bypass grafting (CABG), and age. Results were similar in patients surviving 24 hours post-operation, where intubation time was also the strongest predictor of 30-day (HR 4.18, c-index 0.87) and 1-year (HR 2.81, c-index 0.78) mortality. CONCLUSIONS Intubation time is the strongest predictor of 30-day and 1-year mortality among patients with ischemic heart failure undergoing CABG. Combining intubation time with other mortality risk factors may allow the identification of patients at the highest risk for whom the development of specific strategies may improve outcomes.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada.
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Krzysztof Wrobel
- Department of Cardiac Surgery, Medicover Hospital, Warsaw, Poland
| | - Denis Bouchard
- Department of Surgery, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | | | - Renato A K Kalil
- Postgraduate Program, Instituto de Cardiologia/FUC and UFCSPA, Porto Alegre, Brazil
| | - Craig H Selzman
- Department of Surgery, University of Utah, Salt Lake City, UT
| | - Richard C Daly
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Benjamin Sun
- The Minneapolis Heart Institute, Minneapolis, MN
| | | | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Eric J Velazquez
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jean L Rouleau
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
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Maki Y, Toyoda D, Tomichi K, Onodera J, Kotake Y. Association of Oral Intake and Transient Mixed Venous Oxygen Desaturation in Patients Undergoing Fast-Track Postoperative Care After Open-Heart Surgery. J Cardiothorac Vasc Anesth 2018; 32:2236-2240. [PMID: 29395815 DOI: 10.1053/j.jvca.2017.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The impact of early resumption of oral intake after cardiac surgery on hemodynamics has not been characterized. The authors examined the effects of early oral intake on the oxygen supply-demand relationship in patients undergoing on-pump cardiac surgery in an early recovery after surgery program. DESIGN Prospective data were collected in postcardiac surgical patients in a multidisciplinary intensive care unit (ICU) during an 18-month period. SETTING Single institution study. PARTICIPANTS Forty-three patients who underwent either mitral or aortic valve repair and were successfully liberated from ventilatory support within 10 hours after surgery. INTERVENTIONS Patients were either allowed to resume oral intake on the morning of the first postoperative day or not at the discretion of the surgical team after extubation. MEASUREMENTS AND MAIN RESULTS The oxygen supply-demand relationship was assessed continuously with cardiac index and mixed venous oxygen saturation (SvO2). Among the subjects, 22 patients were allowed to eat, and transient SvO2 decrease was noted in 13 patients. All transient SvO2 decreases occurred in the patients with early oral intake. The hemodynamic status and oxygen supply-demand relationship did not differ between the patients with and without transient SvO2 decrease. All the subjects were discharged successfully from the ICU on the first postoperative day, and the length of hospital stay was similar irrespective of SvO2 decrease after early oral intake. CONCLUSIONS Early oral intake shortly after extubation was associated with transient but significant SvO2 decrease in patients who underwent fast-track recovery after open-heart surgery. Because this phenomenon did not negatively affect the postoperative outcome, early oral intake may not be harmful.
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Affiliation(s)
- Yuichi Maki
- Department of Anesthesiology, Toho University Ohashi Medical Center, Meguro, Tokyo, Japan.
| | - Daisuke Toyoda
- Department of Anesthesiology, Toho University Ohashi Medical Center, Meguro, Tokyo, Japan
| | - Keiko Tomichi
- Department of Anesthesiology, Toho University Ohashi Medical Center, Meguro, Tokyo, Japan
| | - Jun Onodera
- Department of Anesthesiology, Toho University Ohashi Medical Center, Meguro, Tokyo, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, Meguro, Tokyo, Japan
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Lee A, Mu JL, Chiu CH, Gin T, Underwood MJ, Joynt GM. Effect of motor subtypes of delirium in the intensive care unit on fast-track failure after cardiac surgery. J Thorac Cardiovasc Surg 2017; 155:268-275.e1. [PMID: 29110954 DOI: 10.1016/j.jtcvs.2017.08.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/06/2017] [Accepted: 08/16/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of the study was to evaluate the association between motor subtypes of postoperative delirium in the intensive care unit and fast-track failure (a composite outcome of prolonged stay in the intensive care unit >48 hours, intensive care unit readmission, and 30-day mortality) after cardiac surgery. METHODS This was a secondary analysis of a prospective cohort study of 600 consecutive adults undergoing cardiac surgery at a university hospital in Hong Kong (July 2013 to July 2015). The motor subtypes of delirium were classified using the Richmond Agitation Sedation Score and Confusion Assessment Method intensive care unit assessments performed by trained bedside nurses. A generalized estimating equation was used to estimate a common relative risk of fast-track failure associated with motor subtypes. RESULTS The incidences of hypoactive, hyperactive, and mixed motor subtypes were 4.3% (n = 26), 4.0% (n = 24), and 5.5% (n = 33), respectively. Fast-track failure occurred in 88 patients (14.7%). There was an association between delirium (all subtypes) and fast-track failure (P = .048); hyperactive delirium (relative risk, 1.95; 95% confidence interval, 0.96-3.94); hypoactive delirium (relative risk, 2.79; 95% confidence interval, 1.34-5.84); and mixed delirium (relative risk, 2.55; 95% confidence interval, 1.11-5.88). Hypoactive and mixed subtypes were associated with prolonged intensive care unit stay (both P = .001). CONCLUSIONS Patients with pure hypoactive delirium had a similar risk of developing fast-track failure as other motor subtypes. Differentiation of motor subtypes is unlikely to be clinically important for prognostication of fast-track failure. However, because delirium is associated with poor outcomes, potential treatment strategies should address all subtypes equally.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Jing Lan Mu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Chun Hung Chiu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Tony Gin
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Malcolm John Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
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Zakhary WZA, Turton EW, Ender JK. Post-operative patient care and hospital implications of fast track. Eur Heart J Suppl 2017. [DOI: 10.1093/eurheartj/suw055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Heijmans JH, Lancé MD. Fast track minimally invasive aortic valve surgery: patient selection and optimizing. Eur Heart J Suppl 2017. [DOI: 10.1093/eurheartj/suw056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Zakhary W, Lindner J, Sgouropoulou S, Eibel S, Probst S, Scholz M, Ender J. Independent Risk Factors for Fast-Track Failure Using a Predefined Fast-Track Protocol in Preselected Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2015; 29:1461-5. [DOI: 10.1053/j.jvca.2015.05.193] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Indexed: 11/11/2022]
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Youssefi P, Timbrell D, Valencia O, Gregory P, Vlachou C, Jahangiri M, Edsell M. Predictors of Failure in Fast-Track Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1466-71. [DOI: 10.1053/j.jvca.2015.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Indexed: 01/08/2023]
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Kim DJ, Park KH, Isamukhamedov SS, Lim C, Shin YC, Kim JS. Clinical results of cardiovascular surgery in the patients older than 75 years. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:451-7. [PMID: 25346900 PMCID: PMC4207114 DOI: 10.5090/kjtcs.2014.47.5.451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 02/06/2014] [Accepted: 02/10/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The balance of the risks and the benefits of cardiac surgery in the elderly remains a major concern. We evaluated the early and mid-term clinical results of patients aged over 75 years who underwent major cardiovascular surgery. METHODS Two hundred and fifty-one consecutive patients, who underwent cardiac surgery at Seoul National University Bundang Hospital between July 2003 and June 2011, were included in this study (mean age, 78.7±3.4 years; male:female=130:121). Elective surgery was performed in 112 patients, urgent in 90, and emergency in 49. RESULTS Early mortality was 12.7% (32/251). Follow-up completion was 100%, and the mean follow-up duration was 2.8±2.2 years. Late mortality was 24.2% (53/219). There were 283 readmissions in a total of 109 patients after discharge. However, the reason for readmission was related more to non-cardiac factors (71.3%) than to cardiac factors. The overall survival estimates were 79.2% at the 1-year follow-up and 58.4% at the 5-year follow-up. Patients who underwent elective surgery had a lower early mortality rate (elective, 4.5%; urgent, 13.3%; emergency, 30.6%) and better overall survival rate than those that underwent urgent or emergency surgery (p <0.001). CONCLUSION The timing of cardiac surgery was found to be an independent risk factor for early and late mortality. Thus, earlier referral and intervention may improve operative results. Further, comprehensive coordinated postoperative care is needed for other comorbid problems in aged patients.
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Affiliation(s)
- Dong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | | | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Yoon Cheol Shin
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
| | - Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine
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Haanschoten MC, van Straten AHM, ter Woorst JF, Stepaniak PS, van der Meer AD, van Zundert AAJ, Soliman Hamad MA. Fast-track practice in cardiac surgery: results and predictors of outcome. Interact Cardiovasc Thorac Surg 2012; 15:989-94. [PMID: 22951954 DOI: 10.1093/icvts/ivs393] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Marco C Haanschoten
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
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