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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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Wang YC, Huang HH, Lin PC, Wang MJ, Huang CH. Hypothermia is an independent risk factor for prolonged ICU stay in coronary artery bypass surgery: an observational study. Sci Rep 2023; 13:4626. [PMID: 36944855 PMCID: PMC10030842 DOI: 10.1038/s41598-023-31889-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/20/2023] [Indexed: 03/23/2023] Open
Abstract
Maintenance of normothermia is a critical perioperative issue. The warming process after hypothermia tends to increase oxygen demand, which may lead to myocardial ischemia. This study explored whether hypothermia was an independent risk factor for increased morbidity and mortality in patients receiving CABG. We conducted a retrospective observational study of CABG surgeries performed from January 2018 to June 2019. The outcomes of interest were mortality, surgical site infection rate, ventilator dependent time, intensive care unit (ICU) stay, and hospitalization duration. Data from 206 patients were analysed. Hypothermic patients were taller (p = 0.012), had lower left ventricular ejection fraction (p = 0.016), and had off-pump CABG more frequently (p = 0.04). Our analysis noted no incidence of mortality within 30 days. Hypothermia was not associated with higher surgical site infection rate or longer intubation time. After adjusting for sex, age, cardiopulmonary bypass duration, left ventricular ejection fraction, and EuroSCORE II, higher EuroSCORE II (p < 0.001; odds ratio 1.2) and hypothermia upon ICU admission (p = 0.04; odds ratio 3.8) were independent risk factors for prolonged ICU stay. In addition to EuroSCORE II, hypothermia upon ICU admission was an independent risk factor for prolonged ICU stay in patients receiving elective CABG.
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Affiliation(s)
- Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University College of Medicine and National University Hospital, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan, 10002
| | - Hsing-Hao Huang
- Department of Anesthesiology, National Taiwan University College of Medicine and National University Hospital, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan, 10002
| | - Pei-Ching Lin
- Department of Anesthesiology, National Taiwan University College of Medicine and National University Hospital, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan, 10002
| | - Ming-Jiuh Wang
- Department of Anesthesiology, National Taiwan University College of Medicine and National University Hospital, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan, 10002
- National Taiwan University Cancer Center, No. 57, Ln. 155, Sec. 3, Keelung Rd., Da'an Dist., Taipei City, 106, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University College of Medicine and National University Hospital, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan, 10002.
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Djouani A, Smith A, Choi J, Lall K, Ambekar S. Cardiac surgery in the morbidly obese. J Card Surg 2022; 37:2060-2071. [PMID: 35470870 DOI: 10.1111/jocs.16537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery. AIM This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients. METHODS The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed. CONCLUSIONS Data presented identified the benefits of preoperative respiratory muscle training, off-pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.
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Affiliation(s)
- Adam Djouani
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Alexander Smith
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Jeesoo Choi
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Kulvinder Lall
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
| | - Shirish Ambekar
- The Department of Cardiac Surgery, St Bartholomew's Hospital, London, UK
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Kamal F, Abd El-Rahman A, Hassan RM, Helmy AF. Efficacy of bilateral PECS II block in postoperative analgesia for ultrafast track pediatric cardiac anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2043523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Farouk Kamal
- ICU, and Pain Management, Anesthesia, ICU, and Pain Management Department. Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Abd El-Rahman
- ICU, and Pain Management, Anesthesia, ICU, and Pain Management Department. Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Mahmoud Hassan
- ICU, and Pain Management, Anesthesia, ICU, and Pain Management Department. Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amr Fouad Helmy
- ICU, and Pain Management, Anesthesia, ICU, and Pain Management Department. Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Brovman EY, Tolis G, Hirji S, Axtell A, Fields K, Muehlschlegel JD, Urman RD, Deseda GAC, Kaneko T, Karamnov S. Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional Study. J Cardiothorac Vasc Anesth 2022; 36:1258-1264. [PMID: 34980525 DOI: 10.1053/j.jvca.2021.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery. DESIGN A retrospective, observational study. SETTING Two university-affiliated tertiary care centers. PARTICIPANTS A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk. CONCLUSION Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.
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Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - George Tolis
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Sameer Hirji
- Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Andrea Axtell
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - J Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gaston A Cudemis Deseda
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Tsuyoshi Kaneko
- Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sergey Karamnov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
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Wang J, Xie WP, Lei YQ, Wang ZC, Cao H, Chen Q. Clinical effect of dexmedetomidine combined with sufentanil on postoperative analgesia for transthoracic device closure of ventricular septal defects in children with ultrafast track anesthesia. J Cardiothorac Surg 2021; 16:206. [PMID: 34321062 PMCID: PMC8318323 DOI: 10.1186/s13019-021-01592-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background To observe the effect of combining dexmedetomidine with sufentanil on postoperative analgesia in children who underwent transthoracic device closure of ventricular septal defects (VSDs) with ultrafast track anesthesia. Methods This was a retrospective study. Eighty-seven children who underwent transthoracic device closure of VSDs were retrospectively analyzed. Patients were divided into three groups based on the different drugs used for postoperative patient-controlled analgesia. Results No statistically significant differences in hemodynamic parameters were noted among the three groups after surgery (p > 0.05). The FLACC score in the SD2 group was significantly greater than those in the S groups and SD1 groups after surgery (p < 0.001). The Ramsay score in the S group was significantly lower than that of the SD1 and SD2 groups at 6 h (p < 0.001 and p = 0.003), 12 h (p = 0.002 and p = 0.012), and 24 h (p < 0.001 and p < 0.001) after surgery. The pressing frequency of the analgesic pump 48 h after the operation in the SD2 group was significantly greater than that in the other two groups (p < 0.05). The incidences of respiratory depression, nausea, and vomiting in the S group were significantly greater than those in the SD1 and SD2 groups (p < 0.05). Conclusion The combination of 0.04 μg/kg/h dexmedetomidine and 0.04 μg/kg/h sufentanil intravenous analgesia was more effective than the other two analgesic strategies in children who underwent transthoracic device closure of ventricular septal defects (VSDs) with ultrafast track anesthesia.
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Affiliation(s)
- Jing Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Peng Xie
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yu-Qing Lei
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Zeng-Chun Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China. .,Fujian Children's Hospital, Fuzhou, China. .,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China. .,Fujian Children's Hospital, Fuzhou, China. .,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
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Xu J, Zhou G, Li Y, Li N. Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery. BMC Pediatr 2019; 19:487. [PMID: 31829170 PMCID: PMC6907131 DOI: 10.1186/s12887-019-1832-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the outcomes of ultra-fast-track anesthesia (UFTA) and conventional anesthesia in cardiac surgery for children with congenital heart disease (CHD) and low birth weight. METHODS One hundred and ninety-four CHD children, aged 6 months to 2 years, weighting 5 to 10 kg, were selected for this study. The 94 boys and 100 girls with the American Society of Anesthesiologists (ASA) physical status III and IV were randomly divided into two groups each consisting of 97 patients, and were subjected to ultra-fast-track and conventional anesthesia for cardiac surgery. For children in UFTA group, sevoflurane was stopped when cardiopulmonary bypass (CPB) started and cis-atracurium was stopped at the beginning of rewarming, and remifentanil (0.3 μg/kg/mim) was then infused. Propofol and remifentanil were discontinued at skin closure. 10 min after surgery, extubation was performed in operating room. For children in conventional anesthesia group, anesthesia was given routinely and they were directly sent to ICU with a tracheal tube. Extubation time, ICU stay and hospital stay after operation were recorded. Sedation-agitation scores (SAS) were assessed and adverse reactions as well as other anesthesia -related events were recorded. RESULTS The extubation time, ICU stay and hospital stay were significantly shorter in UFTA group (P < 0.05) and SAS at extubation was lower in UFTA group than in conventional anesthesia group, but similar in other time points. For both groups, no airway obstruction and other serious complications occurred, and incidence of other anesthesia -related events were low. CONCLUSIONS UFTA shortens extubation time, ICU stay and hospital stay for children with CHD and does not increase SAS and incidence of adverse reactions.
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Affiliation(s)
- Jing Xu
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Guanghua Zhou
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Yanpei Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
| | - Na Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
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Subramaniam K, DeAndrade DS, Mandell DR, Althouse AD, Manmohan R, Esper SA, Varga JM, Badhwar V. Predictors of operating room extubation in adult cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1656-1665.e2. [DOI: 10.1016/j.jtcvs.2017.05.107] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 05/11/2017] [Accepted: 05/30/2017] [Indexed: 01/26/2023]
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Zayat R, Menon AK, Goetzenich A, Schaelte G, Autschbach R, Stoppe C, Simon TP, Tewarie L, Moza A. Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience. J Cardiothorac Surg 2017; 12:10. [PMID: 28179009 PMCID: PMC5299681 DOI: 10.1186/s13019-017-0573-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/25/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications. METHODS From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVAD ultra ) in 13 patients. After propensity score matching, we compared the LVAD ultra group with a matched group (LVAD match ) receiving conventional anesthesia management. RESULTS Patients in the LVAD ultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival. CONCLUSION In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.
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Affiliation(s)
- Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
| | - Ares K Menon
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Andreas Goetzenich
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Gereon Schaelte
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ruediger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Christian Stoppe
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ajay Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
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Myles PS, McIlroy D. Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques. Semin Cardiothorac Vasc Anesth 2016; 9:5-16. [PMID: 15735840 DOI: 10.1177/108925320500900102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fast-track cardiac anesthesia (FTCA) incorporates early tracheal extubation, decreased length of intensive care unit (ICU) and hospital stay, and (ideally) should avoid or reduce complications to safely achieve cost-savings. A growing body of evidence from randomized trials has identified many anesthetic interventions that can improve outcome after cardiac surgery. These include new short-acting hypnotic, opioid, and neuromuscular blocking drugs. An effective FTCA program requires the appropriate selection of suitable patients, a lowdose opioid anesthetic technique, early tracheal extubation, a short stay in the ICU, and coordinated perioperative care. It is also dependent on the avoidance of postoperative complications such as excessive bleeding, myocardial ischemia, low cardiac output state, arrhythmias, sepsis, and renal failure. These complications will have a much greater adverse effect on hospital length of stay and healthcare costs. A number of clinical trials have identified interventions that can reduce some of these complications. The adoption of effective treatments into clinical practice should improve the effectiveness of FTCA.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia & Pain Management, Alfred Hospital, Victoria, Australia.
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12
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Djaiani G, Fedorko L, Beattie WS. Regional Anesthesia in Cardiac Surgery: A Friend or A Foe? Semin Cardiothorac Vasc Anesth 2016; 9:87-104. [PMID: 15735847 DOI: 10.1177/108925320500900109] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Escalating costs and change in the profile of patients presenting for cardiac surgery requires modification of perioperative management strategies. Regional anesthesia has played an integral part of many fast-track anesthesia protocols across North America and Europe. This review suggests that for patients undergoing coronary artery bypass graft surgery, the risk-to-benefit ratio is in favor of epidural and spinal anesthesia, provided there are no specific contraindications and the guidelines for the use of regional techniques in cardiac surgery are followed. Patients managed with regional techniques seem to benefit from superior postoperative analgesia, shorter postoperative ventilation, reduced incidence of supraventricular arrhythmia, and lower rates of perioperative myocardial infarction. The results of this analysis suggest that for each episode of neurologic complication, 20 myocardial infarctions and 76 episodes of atrial fibrillation would be prevented, thus, we would consider the regional anesthesia and analgesia to be an effective strategy that improves perioperative morbidity. However, other treatment modalities such as the addition of calcium channel blockers, aspirin, and beating heart surgery, are also suggested to be beneficial in cardiac surgical patients and may impose less risk than the use of regional techniques. We believe that the results presented in this review are encouraging enough to permit continued investigation. A prospective, randomized, controlled multicenter trial needs to be adequately powered to answer important clinical questions and allow for a long-term follow-up.
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Affiliation(s)
- George Djaiani
- Department of Anesthesiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Bainbridge D, Cheng DC. Early extubation and fast-track management of off-pump cardiac patients in the intensive care unit. Semin Cardiothorac Vasc Anesth 2016; 19:163-8. [PMID: 25975598 DOI: 10.1177/1089253215584919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Off-pump surgery was the original approach to treating patients with cardiac disease in the era before cardiopulmonary bypass. With the advent and refinement of cardiopulmonary bypass, the use of this technique fell out of favor and was quickly surpassed by on-pump techniques. However, the limitations of bypass surgery, especially for coronary artery bypass procedures, was still significant, leading to renewed interest in this technique. Postoperative care for off-pump coronary artery bypass (OPCAB) surgery presents both a challenge and opportunity to the intensivist. OPCAB patients can be treated in a fast-track manner allowing rapid recovery and early extubation and discharge from the intensive care unit. This is supported through the use of protocols that help standardize care and set expectations for the post-cardiac care team. Importantly, complications that may delay recovery including hypothermia, hypotension, and bleeding must be recognized early and treated aggressively to prevent unwanted complications and intensive care delays. Finally, care of these patients has shifted to the post-anesthesia recovery room, making knowledge of the care of these patients in the early postoperative period essential for cardiac anesthesiologists. This article will discuss the care of OPCAB patients following surgery and include approaches to managing patients who return both intubated and extubated.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
| | - Davy C Cheng
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
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Kianfar AA, Ahmadi ZH, Mirhossein SM, Jamaati H, Kashani BS, Mohajerani SA, Firoozi E, Salehi F, Radmand G, Hashemian SM. Ultra fast-track extubation in heart transplant surgery patients. Int J Crit Illn Inj Sci 2015; 5:89-92. [PMID: 26157651 PMCID: PMC4477402 DOI: 10.4103/2229-5151.158394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Heart transplant surgeries using cardiopulmonary bypass (CPB) typically requires mechanical ventilation in intensive care units (ICU) in post-operation period. Ultra fast-track extubation (UFE) have been described in patients undergoing various cardiac surgeries. Aim: To determine the possibility of ultra-fast-track extubation instead of late extubation in post heart transplant patients. Materials and Methods: Patients randomly assigned into two groups; Ultra fast-track extubation (UFE) group was defined by extubation inside operating room right after surgery. Late extubation group was defined by patients who were not extubated in operating room and transferred to post operation cardiac care unit (CCU) to extubate. Results: The mean cardiopulmonary bypass time was 136.8 ± 25.7 minutes in ultra-fast extubation and 145.3 ± 29.8 minutes in late extubation patients (P > 0.05). Mechanical ventilation duration (days) was 0 days in ultra-fast and 2.31 ± 1.8 days in late extubation. Length of ICU stay was significantly higher in late extubation group (4.2 ± 1.2 days) than the UFE group (1.72 ± 1.5 days) (P = 0.02). In survival analysis there was no significant difference between ultra-fast and late extubation groups (Log-rank test, P = 0.9). Conclusions: Patients undergoing cardiac transplant could be managed with “ultra-fast-track extubation”, without increased morbidity and mortality.
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Affiliation(s)
- Amir Abbas Kianfar
- Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zargham Hossein Ahmadi
- Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Mirhossein
- Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamaati
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Tehran, Iran
| | - Babak Sharif Kashani
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Tehran, Iran
| | - Seyed Amir Mohajerani
- Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran
| | - Ehsan Firoozi
- Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farshid Salehi
- Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Golnar Radmand
- Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran
| | - Seyed Mohammadreza Hashemian
- Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran
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Zaouter C, Imbault J, Labrousse L, Abdelmoumen Y, Coiffic A, Colonna G, Jansens JL, Ouattara A. Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2015; 29:1489-97. [PMID: 26119408 DOI: 10.1053/j.jvca.2015.03.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The robotic totally endoscopic coronary artery bypass graft (TECAB) surgery reduces patients' recovery time. The present trial investigated the feasibility and safety of an initial enhanced recovery after surgery (ERAS) path for patients undergoing robotic beating-heart TECAB and compared it with both conventional surgery and traditional perioperative care. It was hypothesized that the preliminary ERAS pathway associated with a beating-heart TECAB procedure could have a synergistic effect on postoperative patient care. DESIGN Observational retrospective study. SETTING University hospital. PARTICIPANTS Patients scheduled for coronary artery bypass graft and undergoing robotic beating-heart TECAB (n = 38) were compared with those undergoing standard surgery and perioperative care (n = 33). The outcomes were the possibility of tracheal extubation at the end of the surgery and the incidence of postoperative complications. MEASUREMENTS AND MAIN RESULTS The main comorbidities were similar between the 2 groups. Extubation on the operating table in the TECAB group was possible in all cases without requiring prompt endotracheal tube reinsertion. The proportion of patients transfused was significantly lower in the TECAB group (p = 0.009). In addition, the duration of intensive care unit and hospital stay were reduced significantly by 24 hours and by 4 days, respectively, in the TECAB group compared with the standard group (p< 0.05). CONCLUSIONS The present results suggested that a program coupling a beating-heart TECAB with a preliminary ERAS path for patients requiring a single coronary revascularization is feasible and safe. This approach could reduce postoperative mechanical ventilation time, transfusion rate, and both intensive care unit and hospital stay.
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Affiliation(s)
- Cédrick Zaouter
- CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Bordeaux, France.
| | - Julien Imbault
- CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Bordeaux, France; University Bordeaux, Adaptation Cardiovasculaire à l'ischémie, Pessac, France
| | - Louis Labrousse
- CHU de Bordeaux, Service de Chirurgie Cardiaque et Vasculaire, Bordeaux, France
| | | | - Alain Coiffic
- CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Bordeaux, France
| | - Giorgio Colonna
- CHU de Bordeaux, Service de Chirurgie Cardiaque et Vasculaire, Bordeaux, France
| | - Jean-Luc Jansens
- Hôpital Erasme Europe Hospitals, Service de Chirurgie Cardiaque, Brussels, Belgium
| | - Alexandre Ouattara
- CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Bordeaux, France; University Bordeaux, Adaptation Cardiovasculaire à l'ischémie, Pessac, France; INSERM U1034, Adaptation cardiovasculaire à l'ischémie, Pessac, France
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16
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Yu AL, Cai XZ, Gao XJ, Zhang ZW, Ma ZS, Ma LL, Wang LX. Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects. Med Princ Pract 2013; 22:234-8. [PMID: 23296121 PMCID: PMC5586751 DOI: 10.1159/000345844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 11/13/2012] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ai-Lan Yu
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Xing-Zhi Cai
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Xiu-Juan Gao
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Zong-Wang Zhang
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Zeng-Shan Ma
- Department of Cardiac Surgery, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Long-Le Ma
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
- Department of School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, N.S.W., Australia
| | - Le-Xin Wang
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
- Department of School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, N.S.W., Australia
- *Prof. Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, (Australia), E-Mail
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Weismann CG, Yang SF, Bodian C, Hollinger I, Nguyen K, Mittnacht AJ. Early Extubation in Adults Undergoing Surgery for Congenital Heart Disease. J Cardiothorac Vasc Anesth 2012; 26:773-6. [DOI: 10.1053/j.jvca.2012.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Indexed: 11/11/2022]
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Singh KE, Baum VC. Pro: early extubation in the operating room following cardiac surgery in adults. Semin Cardiothorac Vasc Anesth 2012; 16:182-6. [PMID: 22798230 DOI: 10.1177/1089253212451150] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Zhang ZW, Zhang XJ, Li CY, Ma LL, Wang LX. Technical Aspects of Anesthesia and Cardiopulmonary Bypass in Patients Undergoing Totally Thoracoscopic Cardiac Surgery. J Cardiothorac Vasc Anesth 2012; 26:270-3. [DOI: 10.1053/j.jvca.2011.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Indexed: 11/11/2022]
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20
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CRITICAL CARE. Br J Anaesth 2012. [DOI: 10.1093/bja/aer477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Dorsa AG, Rossi AI, Thierer J, Lupiañez B, Vrancic JM, Vaccarino GN, Piccinini F, Raich H, Bonazzi SV, Benzadon M, Navia DO. Immediate Extubation After Off-Pump Coronary Artery Bypass Graft Surgery in 1,196 Consecutive Patients: Feasibility, Safety and Predictors of When Not To Attempt It. J Cardiothorac Vasc Anesth 2011; 25:431-6. [DOI: 10.1053/j.jvca.2010.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Indexed: 11/11/2022]
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22
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Ting PC, Chou AH, Yang MW, Ho ACY, Chang CJ, Chang SC. Postoperative reintubation after planned extubation: A review of 137,866 general anesthetics from 2005 to 2007 in a Medical Center of Taiwan. ACTA ACUST UNITED AC 2010; 48:167-71. [DOI: 10.1016/j.aat.2010.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 08/25/2010] [Accepted: 08/30/2010] [Indexed: 12/20/2022]
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23
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Chamchad D, Horrow JC, Nakhamchik L, Sutter FP, Samuels LE, Trace CL, Ferdinand F, Goldman SM. The Impact of Immediate Extubation in the Operating Room After Cardiac Surgery on Intensive Care and Hospital Lengths of Stay. J Cardiothorac Vasc Anesth 2010; 24:780-4. [DOI: 10.1053/j.jvca.2010.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Indexed: 11/11/2022]
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24
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Sostaric M, Geršak B, Novak-Jankovic V. Early Extubation and Fast-Track Anesthetic Technique for Endoscopic Cardiac Surgery. Heart Surg Forum 2010; 13:E190-4. [DOI: 10.1532/hsf98.20091151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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‘On-table’ extubation in elective paediatric congenital cardiac surgery: A feasibility study in a developing country. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-010-0011-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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26
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Häntschel D, Fassl J, Scholz M, Sommer M, Funkat AK, Wittmann M, Ender J. [Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical]. Anaesthesist 2009; 58:379-86. [PMID: 19189062 DOI: 10.1007/s00101-009-1508-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs. METHOD A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs. RESULTS The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group. CONCLUSIONS The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.
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Affiliation(s)
- D Häntschel
- Abteilung für Anästhesie und Intensivtherapie II, Herzzentrum, Universität Leipzig, Strümpellstr. 39, 04289 Leipzig, Deutschland.
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Bainbridge D, Cheng DCH. Minimally invasive direct coronary artery bypass and off-pump coronary artery bypass surgery: anesthetic considerations. Anesthesiol Clin 2008; 26:437-52. [PMID: 18765216 DOI: 10.1016/j.anclin.2008.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many new surgical technologies are being developed, with the overall aim of improving outcomes. One common feature of many new technologies is that they offer a safer approach than previous techniques; one of the greatest forces for change over the last 30 years is risk reduction. Cardiac surgery risk has been effectively undercut by percutaneous-based procedures, which have offered dramatic reductions in risk--at least in the short term. Beating heart techniques, whether minimally invasive direct coronary artery bypass (MIDCAB), off-pump coronary artery bypass surgery (OPCAB), or in other forms, such as percutaneous valve replacement, are likely to dramatically increase over the next decade. What role OPCAB and MIDCAB techniques will play in this new era is anyone's guess.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, University Hospital-LHSC, 339 Windermere Road, C3-172, London, Ontario, Canada.
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Bracco D, Noiseux N, Dubois MJ, Prieto I, Basile F, Olivier JF, Hemmerling T. Epidural anesthesia improves outcome and resource use in cardiac surgery: a single-center study of a 1293-patient cohort. Heart Surg Forum 2008; 10:E449-58. [PMID: 18187377 DOI: 10.1532/hsf98.20071126] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- David Bracco
- Department of Anesthesiology, Hôtel-Dieu Hospital, Université de Montréal Hospital, Montréal, Québec, Canada.
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Jeong SM, Hahm KD, Jeong YB, Yang HS, Choi IC. Warming of intravenous fluids prevents hypothermia during off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2007; 22:67-70. [PMID: 18249333 DOI: 10.1053/j.jvca.2007.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Even mild perioperative hypothermia (34 degrees -36 degrees C) can cause numerous adverse outcomes, including morbid cardiac events, coagulopathy with increased blood loss, and a decreased resistance to surgical wound infection. The purpose of this study was to evaluate the effect of fluid warming on preventing hypothermia during off-pump coronary artery bypass (OPCAB) surgery. DESIGN A prospective randomized clinical study. SETTING A tertiary care university hospital. PARTICIPANTS Forty patients undergoing OPCAB procedures. INTERVENTIONS Patients were randomized into control (n = 20) and Hotline (n = 20) groups. In the Hotline group, all intravenous fluids were warmed to 41 degrees C by using 2 Hotline (SIMS Inc, Rockland, MD) systems. All patients (control and Hotline groups) were managed with standardized institutional practice by using a combination of increased ambient operating room temperature (to 25 degrees C) and the use of a warmed water mattress (38 degrees C). MEASUREMENTS AND MAIN RESULTS Temperatures were recorded every hour after the induction of anesthesia at the pulmonary artery, nasopharynx, rectum, and bladder. In the Hotline group, temperatures were maintained or increased. In the control group, temperatures gradually decreased. There were no significant differences between the 2 groups in hemodynamic parameters, serum catecholamine concentrations, duration of intensive care unit stay, or duration of ward stay. CONCLUSIONS The results show that the warming of intravenous fluids by using the Hotline system prevents decreases in systemic temperatures during OPCAB surgery.
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Affiliation(s)
- Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
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Abstract
Adequate postoperative analgesia prevents unnecessary patient discomfort. It may also decrease morbidity, postoperative hospital length of stay and, thus, cost. Achieving optimal pain relief after cardiac surgery is often difficult. Many techniques are available, and all have specific advantages and disadvantages. Intrathecal and epidural techniques clearly produce reliable analgesia in patients undergoing cardiac surgery. Additional potential benefits include stress response attenuation and thoracic cardiac sympathectomy. The quality of analgesia obtained with thoracic epidural anesthetic techniques is sufficient to allow cardiac surgery to be performed in awake patients without general endotracheal anesthesia. However, applying regional anesthetic techniques to patients undergoing cardiac surgery is not without risk. Side effects of local anesthetics (hypotension) and opioids (pruritus, nausea/vomiting, urinary retention, and respiratory depression), when used in this manner, may complicate perioperative management. Increased risk of hematoma formation in this scenario has generated much of lively debate regarding the acceptable risk-benefit ratio of applying regional anesthetic techniques to patients undergoing cardiac surgery.
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Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois 60637, USA.
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31
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Turker G, Goren S, Sahin S, Korfali G, Sayan E. Combination of Intrathecal Morphine and Remifentanil Infusion for Fast-Track Anesthesia in Off-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2005; 19:708-13. [PMID: 16326292 DOI: 10.1053/j.jvca.2005.08.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the combination of intrathecal morphine and remifentanil infusion with isoflurane in off-pump coronary artery surgery, with a focus on postoperative analgesia and fast-tracking. DESIGN Prospective, randomized, controlled, blinded clinical study. SETTING University hospital. PARTICIPANTS Forty-six patients who underwent elective off-pump coronary artery bypass grafting. INTERVENTIONS Patients were randomly assigned to receive remifentanil infusion alone (control group, n = 23) or remifentanil infusion plus 10 microg/kg of intrathecal morphine (ITM group, n = 23). Induction and maintenance anesthesia were the same in both groups. Maintenance therapy was remifentanil infusion (0.25-1 microg/kg/min) and 0.5% to 1.5% isoflurane, with adjustments according to hemodynamics. After extubation, intravenous patient-controlled analgesia with morphine (1-mg bolus and 5-minute lockout) was administered, and Wilson sedation scores, visual analog pain scores (scale, 0-100 mm) at rest and during coughing, and cumulative morphine consumption were assessed at 1, 2, 4, 8, 12, 24, and 48 hours. Examiners were unaware of patients' group identities. Anesthetic recovery parameters and opioid-related, spinal anesthesia-related, and cardiac complications were recorded. MEASUREMENTS AND MAIN RESULTS There were no differences between the groups' intraoperative hemodynamic or anesthetic recovery findings. Pain scores and morphine consumption were significantly lower in the ITM group at all time points after extubation (p = 0.0001-0.05). Group frequencies of opioid-related and cardiac complications were similar. No patient had central neuroaxial hematoma or post-spinal tap headache. CONCLUSION In the setting of isoflurane anesthesia for off-pump coronary artery bypass grafting, ITM combined with remifentanil infusion provides better postoperative analgesia than does remifentanil infusion alone, and does not improve or negatively affect fast-tracking.
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Affiliation(s)
- Gurkan Turker
- Department of Anesthesiology and Reanimation, Uludag University Medical School, Gorukle/Bursa, Turkey.
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Alvarez J, Hernández B, Atanassoff PG. High thoracic epidural anesthesia and coronary artery disease in surgical and non-surgical patients. Curr Opin Anaesthesiol 2005; 18:501-6. [PMID: 16534283 DOI: 10.1097/01.aco.0000183104.73931.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Even though high thoracic epidural anesthesia has been shown to be highly efficacious in the control of symptoms in refractory angina, its general use is still restricted. In patients who undergo coronary revascularization, however, the technique is becoming more and more popular. The present review outlines the use of high thoracic epidural anesthesia in patients with ischemic heart disease who underwent coronary revascularization in order to further reveal high thoracic epidural anesthesia's low complication rate and to analyze why physicians still refrain from using it more frequently. RECENT FINDINGS The incidence of severe hemodynamic complications after high thoracic epidural anesthesia is low in patients with coronary artery disease. The main advantage would be a myocardial sympathectomy leading to an improvement in the oxygen input-demand relationship. Likewise, a decrease in mortality due to respiratory complications could not be shown. In patients undergoing myocardial revascularization with full anticoagulation there is an increased risk of epidural hematoma formation. Its precise risk is difficult to evaluate. There is an overall low rate of epidural hematomas as a result of high thoracic epidural anesthesia. With the available data, the incidence has been estimated at between 1/1500 and 1/10,000. SUMMARY Epidural anesthesia does not decrease mortality or the incidence of myocardial infarction after coronary artery bypass grafting. It reduces the incidence of arrhythmias and respiratory complications and improves the quality of analgesia. High thoracic epidural anesthesia has been shown to be a safe and efficient technique for refractory angina that reduces the frequency of ischemic events and improves the clinical condition of patients.
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Affiliation(s)
- Julian Alvarez
- Department of Anesthesia, University Hospital, Santiago de Compostela, Spain.
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Hemmerling TM, Lê N, Olivier JF, Choinière JL, Basile F, Prieto I. Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia. J Cardiothorac Vasc Anesth 2005; 19:176-81. [PMID: 15868524 DOI: 10.1053/j.jvca.2005.01.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has been published focusing on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using either thoracic epidural analgesia or opioid-based analgesia. DESIGN Prospective audit, pilot study. SETTING Single-institution university medical center. PARTICIPANTS Adult patients undergoing aortic valve replacement (N = 45). INTERVENTIONS Forty-five patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. Induction of anesthesia was done using fentanyl, 2 to 4 mug/kg, propofol, 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium; anesthesia was maintained using sevoflurane titrated according to bispectral index (BIS [BIS target: 50]). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA group, bupivacaine 0.125%, 6 to 14 mL/h) or fentanyl, up to 10 microg/kg, followed by patient-controlled analgesia with morphine (OPIOID group). MEASUREMENTS AND MAIN RESULTS Success of extubation within 30 minutes after surgery was recorded. Hemodynamic data during surgery were compared by using an analysis of variance test; p < 0.05 was considered as showing a significant difference. Data presented as median (25th-75th percentile). In the TEA group, patients underwent simple aortic valve replacement (N = 21) or combined aortic valve surgery (N = 14), with additional coronary artery bypass grafting (N = 10) and replacement of the ascending aorta (Bentall, N = 4). In the OPIOID group, patients underwent simple aortic valve replacement (N = 5) or combined aortic valve surgery (N = 5), with additional aortocoronary bypass grafting (N = 2), replacement of the ascending aorta (Bentall, N = 2), and reconstruction of the mitral valve (N = 1). All 45 patients were extubated within 15 minutes after surgery. There was no need for reintubation; pain scores were lower in the TEA group than in the OPIOID group immediately after surgery and at 6 hours, 24 hours, and 48 hours after surgery. For the TEA group and OPIOID group, the pain scores were 0 (0-2), 0 (0-2), 0 (0-1.5), and 0 (0-0) and 5 (4-5.75), 4 (3-4.5), 4 (3.25-4), and 1 (0-2.5), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic difference between the TEA and OPIOID groups. Eighteen of 45 patients needed temporary pacemaker activation. There were no epidural hematoma or neurologic complications related to TEA. CONCLUSION Immediate extubation is feasible after aortic valve surgery using either high thoracic epidural analgesia or opioid-based analgesia; both techniques maintain hemodynamic stability throughout surgery. TEA provides superior pain control.
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Affiliation(s)
- Thomas M Hemmerling
- Perioperative Cardiac Research Group (PeriCARG, Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Montes FR, Maldonado JD, Paez S, Ariza F. Off-pump versus on-pump coronary artery bypass surgery and postoperative pulmonary dysfunction. J Cardiothorac Vasc Anesth 2005; 18:698-703. [PMID: 15650976 DOI: 10.1053/j.jvca.2004.08.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate how off-pump coronary artery bypass grafting (CABG) affects postoperative pulmonary function when compared with on-pump CABG. DESIGN Prospective clinical study. SETTING University-affiliated teaching hospital. PARTICIPANTS Adult patients (n = 39) undergoing elective coronary artery bypass surgery with or without cardiopulmonary bypass. INTERVENTIONS Two groups of patients were compared: 19 consecutive patients undergoing off-pump CABG surgery and 20 consecutive patients undergoing conventional CABG surgery. MEASUREMENTS AND MAIN RESULTS Pulmonary function tests (flow volume loops and lung volumes with plethysmography) were done preoperatively and 72 hours postoperatively. Arterial blood gases and PaO2/FIO2 were measured at various stages. Sequential chest x-rays were obtained and evaluated for pleural changes, pulmonary edema, and atelectasis. In both groups, PaO2/FIO2 ratios decreased progressively throughout the perioperative period, with no significant differences between the groups at any stage during the study. There was a significant decline in postoperative pulmonary function tests in both groups, but there was no difference between groups at 72 hours postoperatively. No differences were found in the time to extubation, atelectasis scores, or postoperative complications. CONCLUSIONS Off-pump CABG does not confer major protection from postoperative pulmonary dysfunction compared with CABG surgery with CPB. Strategies for minimizing pulmonary impairment after CABG surgery should be directed to factors other than the use of CPB.
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Affiliation(s)
- Félix R Montes
- Department of Anesthesiology, Fundación Cardio Infantil, Instituto de Cardiología, Universidad del Rosario, Bogotá, Colombia.
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Cheng DCH. Routine Immediate Extubation in the Operating Room After OPCAB Surgery: Benefits for Patients, Practitioners, or Providers? J Cardiothorac Vasc Anesth 2005; 19:279-81. [PMID: 16130050 DOI: 10.1053/j.jvca.2005.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Horswell JL, Herbert MA, Prince SL, Mack MJ. Routine Immediate Extubation After Off-Pump Coronary Artery Bypass Surgery: 514 Consecutive Patients. J Cardiothorac Vasc Anesth 2005; 19:282-7. [PMID: 16130051 DOI: 10.1053/j.jvca.2005.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey L Horswell
- Cardiopulmonary Research Science and Technology Institute, Dallas, TX 75230, USA.
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Kessler P, Aybek T, Neidhart G, Dogan S, Lischke V, Bremerich DH, Byhahn C. Comparison of three anesthetic techniques for off-pump coronary artery bypass grafting: General anesthesia, combined general and high thoracic epidural anesthesia, or high thoracic epidural anesthesia alone. J Cardiothorac Vasc Anesth 2005; 19:32-9. [PMID: 15747266 DOI: 10.1053/j.jvca.2004.11.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study compared general anesthesia (GA), combined GA plus thoracic epidural anesthesia (TEA), and TEA alone in patients scheduled for off-pump coronary artery bypass grafting. DESIGN Prospective, nonrandomized clinical study SETTING University hospital. PARTICIPANTS Ninety consenting patients undergoing beating-heart coronary artery revascularization with comparable coronary status and left ventricular function. INTERVENTIONS GA (n=30) was conducted with propofol, remifentanil, and cisatracurium or combined with TEA (GA+TEA, n=30) or TEA as the sole anesthetic with ropivacaine plus sufentanil (TEA, n=30). MEASUREMENTS AND MAIN RESULTS Groups were comparable regarding the surgical approaches and the number of anastomoses. Four patients (GA, n=2; GA+TEA, n=2) who required unplanned cardiopulmonary bypass, and 4 patients in the TEA group who underwent unexpected intubation because of pneumothorax (n=2), phrenic nerve palsy, or incomplete analgesia were excluded from further analysis. Intraoperative heart rate decreased significantly with both GA+TEA and TEA. None of the patients with TEA alone was admitted to the intensive care unit, they all were monitored on average for 6 hours postoperatively in the intermediate care unit and allowed to eat and drink as desired on admission. Postoperative pain scores were lower in both groups with TEA. There were no differences among groups in patients overall satisfaction. CONCLUSION Based on the authors data, all anesthetic techniques were equally safe from the clinicians standpoint. However, GA+TEA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good hemodynamic stability and reliable postoperative pain relief. Nonetheless, the actual and potential risks of TEA during cardiac surgery should not be underestimated.
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Affiliation(s)
- Paul Kessler
- Department of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Friedrichsheim Foundation, Frankfurt, Germany.
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Bestas A, Yasar MA, Bayar MK, Inalkac S. The Effects of Two Different Anaesthesia Techniques on Bispectral Index Values and Awareness During Off-Pump Coronary Artery Bypass Grafting. J Clin Monit Comput 2004; 18:347-51. [PMID: 15957626 DOI: 10.1007/s10877-005-7320-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate Bispectral Index values and awareness during two different anaesthesia regimens (fentanyl-propofol and fentanyl-midazolam) in patients undergoing off-pump CABG surgery. METHODS Fifty patients were included in the study. Patients were premedicated with midazolam and were randomly divided into two groups. Anaesthesia was induced with fentanyl (7-15 microg/kg), with either propofol (2 - 2.5 mg/kg, Group I) or midazolam (0.1 - 0.3 mg/kg, Group II) and vecuronium (0.1 mg/kg). Anaesthesia was maintained with fentanyl (15 microg/kg/h) together with either propofol (6 mg/kg/h) or midazolam (0.1 mg/kg/h). Depth of anaesthesia was adjusted according to clinical signs and haemodynamic responses. The level of sedation was monitored with Bispectral index continuously, but these levels were not shown to the attending anaesthetist. Bispectral index values were recorded for nine phases. Twenty-four hours after the operation, the patients were interviewed to determine intraoperative awareness and recall. RESULTS In all patients, Bispectral index values were found to decrease after induction (in Group I, p = 0.005, in Group II, p = 0.008) with the mean values remaining below 60 for all phases. The differences between the groups were not statistically significant in inter-group comparison. No patients were noted to recall the sounds presented during the operation and the preoperative events. CONCLUSIONS BIS monitoring with clinical signs may be used to assess the adequacy of both types of anaesthesia techniques as well as to detect awareness during off-pump CABG surgery.
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Affiliation(s)
- Azize Bestas
- Department of Anaesthesiology, Firat University School of Medicine, Elazig, Turkey.
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Metz S, Schwann N, Hassanein W, Yuskevich B, Nixon T. Intrathecal morphine for off-pump coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2004; 18:451-3. [PMID: 15365926 DOI: 10.1053/j.jvca.2004.05.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine if preinduction intrathecal morphine is associated with successful intraoperative extubation in patients undergoing off-pump coronary artery bypass grafting. DESIGN A retrospective noncontrolled chart review of all patients undergoing off-pump coronary artery bypass grafting. SETTING Single university hospital. PARTICIPANTS One hundred twelve patients. INTERVENTIONS One hundred twelve of 150 patients received preinduction intrathecal morphine as part of routine anesthetic care for off-pump coronary artery bypass grafting. Patients received a mean of 1.0 mg of intrathecal morphine (range 0.3-1.6 mg); average weight-corrected dose was 13.2 microg/kg (range 5-24 microg/kg). MEASUREMENTS AND MAIN RESULTS This study included intraoperative extubation rate, delayed respiratory depression, and other complications potentially attributable to intrathecal morphine. An intraoperative extubation rate of 77% was found. Five patients received naloxone postoperatively, 4 of them for delayed respiratory depression. CONCLUSIONS It is concluded that intrathecal morphine is associated with a high intraoperative extubation rate in patients undergoing off-pump coronary artery bypass grafting. The authors' practice included 24-hour respiratory monitoring to detect delayed respiratory depression.
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Affiliation(s)
- Samuel Metz
- Department of Anesthesiology, Drexel University College of Medicine, Philadelphia, PA, USA.
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Raja SG, Dreyfus GD. Off-pump coronary artery bypass surgery: To do or not to do? Current best available evidence. J Cardiothorac Vasc Anesth 2004; 18:486-505. [PMID: 15365936 DOI: 10.1053/j.jvca.2004.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Middlesex, United Kingdom.
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Salvi L, Sisillo E, Brambillasca C, Juliano G, Salis S, Marino MR. High thoracic epidural anesthesia for off-pump coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2004; 18:256-62. [PMID: 15232802 DOI: 10.1053/j.jvca.2004.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the feasibility of high thoracic epidural anesthesia combined with sevoflurane for off-pump coronary artery bypass surgery and to evaluate the postoperative pain control, side effects, and perioperative hemodynamics. DESIGN Retrospective review of prospectively collected data. SETTING A university teaching hospital. PARTICIPANTS One hundred six consecutive patients receiving thoracic epidural combined with sevoflurane. INTERVENTION From November 1999, the patients undergoing off-pump coronary artery bypass grafting were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS Insertion of the epidural catheter was successful in all but 2 patients; 1 bloody tap occurred and the dura was never punctured, although 1 patient presented with postoperative paraplegia. An emergency spinal cord nuclear magnetic resonance excluded signs of medullary compression caused by epidural or spinal hematoma. Visual analog scale scores for pain during the first 24-hour period were < 2 in all patients. Mean time to extubation was 4.6 +/- 2.9 hours. The average intensive care unit stay was 1.5 +/- 0.8 days. Incidences of perioperative myocardial infarction, myocardial ischemia, and atrial fibrillation were 2.8%, 7.5%, and 10.6%, respectively. Two patients died: 1 from multiorgan failure and the other from myocardial infarction. Heart rate, mean arterial pressure, cardiac index, and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and cardiac index decreased (p < 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. CONCLUSIONS Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary artery bypass surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.
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Affiliation(s)
- Luca Salvi
- Department of Anesthesia and Intensive Care, URCCS, Centro Cardiologico Monzino, Milan, Italy.
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Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management †. Br J Anaesth 2004; 92:400-13. [PMID: 14970136 DOI: 10.1093/bja/aeh064] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increasing interest is being shown in beating heart (off-pump) coronary artery surgery (OPCAB) because, compared with operations performed with cardiopulmonary bypass, OPCAB surgery may be associated with decreased postoperative morbidity and reduced total costs. Its appears to produce better results than conventional surgery in high-risk patient populations, elderly patients, and those with compromised cardiac function or coagulation disorders. Recent improvements in the technique have resulted in the possibility of multiple-vessel grafting in all coronary territories, with a graft patency comparable with conventional surgery. During beating-heart surgery, anaesthetists face two problems: first, the maintenance of haemodynamic stability during heart enucleation necessary for accessing each coronary artery; and second, the management of intraoperative myocardial ischaemia when coronary flow must be interrupted during grafting. The anaesthetic technique is less important than adequate management of these two major constraints. However, experimental and recent clinical data suggest that volatile anaesthetics have a marked cardioprotective effect against ischaemia, and might be specifically indicated. OPCAB surgery requires team work between anaesthetists and surgeons, who must be aware of each other's constraints. Some surgical aspects of the operation are reviewed along with physiological and anaesthetic data.
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Affiliation(s)
- P-G Chassot
- Departments of Anaesthesiology and Cardiovascular Surgery, University Hospital Lausanne (CHUV), CH-1011 Lausanne, Switzerland
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Hemmerling TM, Prieto I, Choinière JL, Basile F, Fortier JD. Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epiduralbased anesthesia. Can J Anaesth 2004; 51:163-8. [PMID: 14766694 DOI: 10.1007/bf03018777] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA). METHODS One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets. RESULTS Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05). CONCLUSION Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.
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Affiliation(s)
- Thomas M Hemmerling
- Department of Anesthesiology, Centre hospitalier de l'université de Montréal, Hôtel-Dieu, Université de Montréal, Montréal, Québec, Canada.
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Abstract
Total intravenous anaesthesia (TIVA) has many advocates and offers potential benefits, yet the direct costs of this technique are commonly greater than those of inhalation-based alternatives. Although many advantages are claimed for TIVA, in reality all modern anaesthetics are effective and have good safety and tolerability profiles, rendering these differences of less importance now than was perhaps once the case. The majority of direct comparisons between inhaled and intravenous anaesthetics have failed to demonstrate significant differences in recovery times, yet they have consistently shown greater direct costs associated with intravenous propofol anaesthesia. It is commonly believed that indirect costs may be offset by indirect savings achieved through more rapid recovery, reduction in adverse effects and decreased staff workloads. In some cases, these differences in outcome have not been observed, while in many where they have, indirect savings are only theoretical. Reductions in recovery time and nursing workload will only result in savings if fewer nurses are required or if the existing ones can be paid for fewer hours. Salary arrangements, peak demand for patient care, performance of multiple tasks in parallel and limitations in time accounting methodology all limit the ability to achieve such savings in reality. Drug wastage also contributes to the cost of anaesthesia and is common to both intravenous and inhaled techniques. With inhaled anaesthesia, wastage can be reduced by the use of lower fresh gas flows, which has no adverse consequences and may provide potential benefits. With intravenous anaesthesia, reducing drug wastage is difficult and potentially harmful through cross-contamination of drugs between patients. Recently, the cost of propofol has been reduced with the availability of generics, making TIVA a more attractive proposition. The costs of several inhaled anaesthetics have also decreased, however, reducing any relative benefit. Nevertheless, the net result of lowered costs is that all types of anaesthetic drugs, which typically comprise <5% of a hospital pharmacy budget, represent excellent value for money. With few new products in the immediate pipeline and most established drugs already generic or about to lose their patent protection, the expense of anaesthesia is likely to decline even further. Perhaps then we will be able to stop arguing over relatively small differences in cost and choose a technique that, in our own experienced hands, provides the best and safest patient outcomes.
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Affiliation(s)
- Ian Smith
- North Staffordshire Hospital, Stoke-on-Trent, UK
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Hemmerling TM, Choinière JL, Fortier JD, Prieto I, Basile F. Immediate extubation after aortic valve surgery using high thoracic epidural anesthesia: a pilot study. Anesth Analg 2003; 97:601. [PMID: 12873961 DOI: 10.1213/01.ane.0000074531.64117.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Thomas M Hemmerling
- Department of Anesthesiology Department of Surgery Centre Hospitalier de l'Université de Montréal (CHUM) Université de Montréal Montréal, Québec, Canada
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Abstract
Off-pump coronary artery bypass presents special challenges for the anesthesiologist and surgeon, who must work closely together to provide optimal care. Displacement and immobilization of the heart for exposure of the coronary arteries, as well as occlusion of these vessels, can result in periods of significant hemodynamic instability. Appropriate preparation, guided therapy, and technical maneuvers can lessen such adverse hemodynamic impact. It is important for anesthesiologists to be aware of the special problems associated with this surgery, as well as the different therapies and maneuvers that can be useful in providing the best possible care. As surgeons develop greater expertise and better devices for the management of these patients, the number of coronary revascularizations without CPB is likely to increase.
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Affiliation(s)
- Luis G Michelsen
- Division of Cardiothoracic Anesthesia, Pinnacle Anesthesia Consultants and Texas Cardiopulmonary Research Science and Technology Institute, Dallas, TX, USA
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Servin F. Remifentanil; from Pharmacological Properties to Clinical Practice. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 523:245-60. [PMID: 15088856 DOI: 10.1007/978-1-4419-9192-8_22] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Barvais L, Sutcliffe N. Remifentanil for Cardiac Anaesthesia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 523:171-87. [PMID: 15088850 DOI: 10.1007/978-1-4419-9192-8_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Luc Barvais
- Erasmus hospital, 808 Lennikstreet, Brussels, Belgium
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Bowler I, Djaiani G, Abel R, Pugh S, Dunne J, Hall J. A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. J Cardiothorac Vasc Anesth 2002; 16:709-14. [PMID: 12486651 DOI: 10.1053/jcan.2002.128414] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN Prospective, randomized, controlled clinical trial. SETTING Referral center for cardiothoracic surgery at a university hospital. PARTICIPANTS Patients (n = 24) undergoing first-time elective CABG surgery. INTERVENTIONS Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 microg/kg bolus followed by 0.25 to 1 microg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 microg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled. MEASUREMENTS AND MAIN RESULTS Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 +/- 82 minutes and 258 +/- 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 +/- 3 mg in the RITM group and 16 +/- 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO(2) and PaCO(2) after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups. CONCLUSION Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation.
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Affiliation(s)
- Ian Bowler
- Department of Anesthesia, University Hospital of Wales, United Kingdom
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