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Teman NR, Strobel RJ, Bonnell LN, Preventza O, Yarboro LT, Badhwar V, Kaneko T, Habib RH, Mehaffey JH, Beller JP. Operating Room Extubation for Patients Undergoing Cardiac Surgery: A National Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2024; 118:692-699. [PMID: 38878949 DOI: 10.1016/j.athoracsur.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The utility of operating room extubation (ORE) after cardiac surgery over fast-track extubation (FTE) within 6 hours remains contested. We hypothesized ORE would be associated with equivalent rates of morbidity and mortality, relative to FTE. METHODS Patients undergoing nonemergent cardiac surgery were identified in The Society of Thoracic Surgeons Adult Cardiac Surgery Database between July 2017 and December 2022. Only procedures with The Society of Thoracic Surgeons risk models were included. Risk-adjusted outcomes of ORE and FTE were compared by observed-to-expected ratios with 95% CIs aggregated over all procedure types, and ORE vs FTE adjusted odds ratios (ORs) specific to each procedure type using multivariable logistic regression. Analyzed outcomes were operative mortality, prolonged length of stay, composite reoperation for bleeding and reintubation, and composite morbidity and mortality. RESULTS The study population of 669,099 patients across 1069 hospitals included 36,298 ORE patients in 296 hospitals. Risk-adjusted analyses found that ORE was associated with statistically similar or better results across each of the 4 outcomes and procedure subtypes. Notably, rates of postoperative mortality were significantly lower in ORE patients undergoing coronary artery bypass grafting (OR, 0.54; 95% CI, 0.46-0.65), aortic valve replacement (OR, 0.43; 95% CI, 0.24-0.77), and mitral valve replacement (OR, 0.48; 95% CI, 0.26-0.89). CONCLUSIONS Extubation in the OR was safe and effective in a selected patient population and may be associated with superior outcomes in coronary artery bypass, aortic valve replacement, and mitral valve replacement. These national data appear to confirm institutional experiences regarding the potential benefit of OR extubation. Further refinement of optimal populations may justify randomized investigation.
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Affiliation(s)
- Nicholas R Teman
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia.
| | - Raymond J Strobel
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Levi N Bonnell
- The Society of Thoracic Surgeons Research and Analytic Center, Chicago, Illinois
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St Louis, Missouri
| | - Robert H Habib
- The Society of Thoracic Surgeons Research and Analytic Center, Chicago, Illinois
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Jared P Beller
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
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Stock S, Berger Veith S, Holst T, Erfani S, Pochert J, Dumps C, Girdauskas E. Feasibility of deescalating postoperative care in enhanced recovery after cardiac surgery. Front Cardiovasc Med 2024; 11:1412869. [PMID: 39188324 PMCID: PMC11345171 DOI: 10.3389/fcvm.2024.1412869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/29/2024] [Indexed: 08/28/2024] Open
Abstract
Introduction Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring. Methods 358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU). Results Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery (n = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement (n = 79) and aortic surgery (n = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU. Conclusions If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sarah Berger Veith
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Theresa Holst
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sahab Erfani
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Julia Pochert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Dumps
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
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3
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Malvindi PG, Bifulco O, Berretta P, Galeazzi M, Zingaro C, D'Alfonso A, Zahedi HM, Munch C, Di Eusanio M. On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery. Eur J Cardiothorac Surg 2024; 65:ezae010. [PMID: 38230801 DOI: 10.1093/ejcts/ezae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/15/2023] [Accepted: 01/15/2024] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVES Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery. METHODS Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home. RESULTS Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7. CONCLUSIONS Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Alessandro D'Alfonso
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Hossein M Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
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Carnero-Alcázar M, Beltrao-Sial R, Montero-Cruces L, López-Vyzcaino M, Pérez-Camargo D, Sánchez R, Cobiella-Carnicer J, Fernández-Velasco D, Maroto-Castellanos LC. Ultrafast track versus conventional fast track in patients undergoing cardiac surgery: a propensity score-matched analysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad143. [PMID: 37607006 PMCID: PMC10460483 DOI: 10.1093/icvts/ivad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 08/21/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVES We aimed at comparing the risk of major adverse events and length of stay between patients undergoing ultrafast track and conventional fast track. METHODS Retrospective cohort study adjusted by propensity score matching, including patients operated on between March 2020 and December 2022 of any of the following: coronary, valve surgery or ascending aorta surgery. Patients were divided into 2 groups: ultrafast track: extubation in the operating room and fast track: extubation attempted in the first 6 postoperative hours. The primary objective was to compare the risk of the combined event death, lung respiratory outcomes (reintubation, mechanical ventilation longer than 24 h or pneumonia), or acute renal failure. RESULTS A total of 1126 patients were included. A total of 579 (51.4%) were extubated in the operating room. A total of 331 pairs were available after matching by propensity score. The risk of the primary outcome was 11.8% (n = 39) in the fast-track group and 6.3% (n = 21) in the ultrafast-track group (P = 0.013), mostly driven by lung adverse events (6.9% vs 2.4%, P = 0.011) while no significant differences were detected in the risk of death (2.4% vs 1.8%, P = 0.77) or acute renal failure (8% vs 6.3%, P = 0.56). The risk of myocardial infarction was higher in the fast-track group (2.7% vs 0%, P = 0.039). The median length of stay in the postoperative intensive care unit was longer in the fast-track group [24.7 h (interquartile range 21.5; 62.9) vs 23.5 h (interquartile range 22; 46), P = 0.015]. CONCLUSIONS In patients undergoing cardiac surgery, extubation in the operating room is associated to a lower risk of postoperative complications (mostly driven by lung adverse events) and length of stay in intensive care unit as compared to fast track.
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Affiliation(s)
| | - Rosa Beltrao-Sial
- Department of Anesthesiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | - Rubén Sánchez
- Department of Anesthesiology, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Luis C Maroto-Castellanos
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
- Complutense University, Madrid, Spain
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Hawkins AD, Strobel RJ, Mehaffey JH, Hawkins RB, Rotar EP, Young AM, Yarboro LT, Yount K, Ailawadi G, Joseph M, Quader M, Teman NR. Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs. Semin Thorac Cardiovasc Surg 2022; 36:195-208. [PMID: 36460133 PMCID: PMC10225475 DOI: 10.1053/j.semtcvs.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/02/2022]
Abstract
Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.
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Affiliation(s)
- Andrew D Hawkins
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Raymond J Strobel
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Evan P Rotar
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Andrew M Young
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Kenan Yount
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark Joseph
- Carilion Clinic Cardiothoracic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia.
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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8
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Abstract
Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.
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9
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Yu H, Zhao DL, Ye YC, Zheng JQ, Guo YQ, Zhu T, Liang P. Extubation in the Operating Room After Transapical Transcatheter Aortic Valve Implantation Safely Improves Time-Related Outcomes and Lowers Costs: A Propensity Score-Matched Analysis. J Cardiothorac Vasc Anesth 2020; 35:1751-1759. [PMID: 32873488 DOI: 10.1053/j.jvca.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The experience of safe extubation in the operating room (OR) after transcatheter aortic valve implantation (TAVI) procedure remains not well established. The authors conducted this study to assess the effect of OR extubation in comparison with extubation in the intensive care unit (ICU) on the outcomes and cost in patients undergoing transapical-TAVI. DESIGN A propensity score-matched analysis. SETTING A single major urban teaching and university hospital. PARTICIPANTS A total of 266 patients undergoing transapical TAVI under general anesthesia between June 2015 and March 2020. INTERVENTIONS Propensity matching on pre- and intraoperative variables was used to identify 99 patients undergoing extubation in the OR versus 72 undergoing extubation in the ICU for outcome analysis. MEASUREMENTS AND MAIN RESULTS After matching, extubation in the OR showed significant reductions of length of stay (LOS) in ICU (38.8 ± 17.4 v 58.0 ± 70.0 h, difference -19.2, 95% confidence interval [CI] -35.7 to -2.7, p = 0.009) and postoperative LOS in hospital (7.1 ± 3.9 v 10.1 ± 4.6 d, difference -3.0, 95% CI -4.3 to -1.7, p < 0.0001) compared with ICU extubation, but did not significantly affect the composite incidence of any postoperative complications (46.5% [46 of 99] v 52.8% [38 of 72], difference -6.3%, 95% CI -21.5 to 8.9, p = 0.415). Also, extubation in the OR led to significant reduction of total hospital cost compared with extubation in the ICU (¥303.5 ± 17.3 v ¥329.9 ± 52.3 thousand, difference -26.2, 95% CI -38.8 to -13.7, p < 0.0001). CONCLUSIONS The current study provided evidence that extubation in the OR could be performed safely without increases in morbidity, mortality, or reintubation rate and could provide cost-effective outcome benefits in patients undergoing transapical-TAVI.
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Affiliation(s)
- Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Dai-Liang Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Yuan-Cai Ye
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Jian-Qiao Zheng
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Ying-Qiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Peng Liang
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China.
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Lima CA, Ritchrmoc MK, Leite WS, Silva DARG, Lima WA, Campos SL, de Andrade AD. Impact of fast-track management on adult cardiac surgery: clinical and hospital outcomes. Rev Bras Ter Intensiva 2019; 31:361-367. [PMID: 31618356 PMCID: PMC7005967 DOI: 10.5935/0103-507x.20190059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 05/13/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To compare the impact of two fast-track strategies regarding the extubation time and removal of invasive mechanical ventilation in adults after cardiac surgery on clinical and hospital outcomes. METHODS This was a retrospective cohort study with patients undergoing cardiac surgery. Patients were classified according to the extubation time as the Control Group (extubated 6 hours after admission to the intensive care unit, with a maximum mechanical ventilation time of 18 hours), Group 1 (extubated in the operating room after surgery) and Group 2 (extubated within 6 hours after admission to the intensive care unit). The primary outcomes analyzed were vital capacity on the first postoperative day, length of hospital stay, and length of stay in the intensive care unit. The secondary outcomes were reintubation, hospital-acquired pneumonia, sepsis, and death. RESULTS For the 223 patients evaluated, the vital capacity was lower in Groups 1 and 2 compared to the Control (p = 0.000 and p = 0.046, respectively). The length of stay in the intensive care unit was significantly lower in Groups 1 and 2 compared to the Control (p = 0.009 and p = 0.000, respectively), whereas the length of hospital stay was lower in Group 1 compared to the Control (p = 0.014). There was an association between extubation in the operating room (Group 1) with reintubation (p = 0.025) and postoperative complications (p = 0.038). CONCLUSION Patients undergoing fast-track management with extubation within 6 hours had shorter stays in the intensive care unit without increasing postoperative complications and death. Patients extubated in the operating room had a shorter hospital stay and a shorter stay in the intensive care unit but showed an increase in the frequency of reintubation and postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Armele Dornelas de Andrade
- Universidade Federal do Rio Grande do Norte - Natal (RN), Brasil
- Universidade Federal de Pernambuco - Recife (PE), Brasil
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Akhtar MI, Momeni M, Szekely A, Hamid M, El Tahan MR, Rex S. Multicenter International Survey on the Clinical Practice of Ultra-Fast-Track Anesthesia with On-Table Extubation in Pediatric Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:406-415. [DOI: 10.1053/j.jvca.2018.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/12/2022]
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12
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Nagre AS, Jambures NP. Comparison of immediate extubation versus ultrafast tracking strategy in the management of off-pump coronary artery bypass surgery. Ann Card Anaesth 2018; 21:129-133. [PMID: 29652272 PMCID: PMC5914211 DOI: 10.4103/aca.aca_135_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Ultrafast tracking of anesthesia (UFTA) is practiced routinely, whereas immediate on-table extubation after off-pump coronary artery bypass (OPCAB) grafting surgery has many concerns. The purpose of our study was to evaluate the safety and feasibility of immediate extubation (IE) versus UFTA. Methods: Sixty patients were enrolled who underwent OPCAB surgery. The two groups IE and UFTA had thirty patients each. Inclusion criteria were patients for OPCAB surgery including left main stenosis. Exclusion criteria were patients with Ejection Fraction(EF) <30%, with unstable hemodynamics, on intra-aortic balloon pump (IABP), with renal dysfunction, with associated valvular heart diseases, on inotropes, on temporary pacemaker, with intraoperative conversion to on-pump coronary artery bypass grafting (CABG), who are chronic smokers, and with chronic obstructive pulmonary disease. Statistical analysis was done with Minitab 15 software. Descriptive statistics were summarized as mean, standard deviation, and percentage. Student's t-test was used to determine the significance of normally distributed parametric values. Z-test was used for proportion. Statistical significance was accepted at P < 0.05. Results: OT extubation was found to be safe as no patient had reintubation or respiratory insufficiency. None of the patients in either group had postoperative myocardial infarction, stroke, low cardiac output, mediastinitis, and renal failure. Hypothermia, blood transfusion, atrial fibrillation, and re-exploration did not occur. Intensive Care Unit length of stay was similar in the two groups. Discharge day is statistically significant (P = 0.001), with 5.66 days in the IE group and 6.36 days in the UFTA group. Time spent in the operating room at the end of surgery is statistically significant, with 14.03 min in UFTA group and 33.9 min in IE group. Conclusion: IE appears to be safe and effective in OPCAB patients without any major complications. It can be achieved after fulfilling traditional extubation criteria but is confined to highly selective group of patients.
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Affiliation(s)
- Amarja Sachin Nagre
- Department of Cardiac Anaesthesia, MGM Medical College and MCRI, Aurangabad, Maharashtra, India
| | - Nagesh P Jambures
- Department of Cardiac Anaesthesia, MGM Medical College and MCRI, Aurangabad, Maharashtra, India
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13
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Bainbridge D, Cheng D. Initial Perioperative Care of the Cardiac Surgical Patient. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320200600306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recently, changes in the management of cardiac patients have allowed earlier discharge from the cardiac recovery area and reduced hospital length of stay. These changes have been drien by a need to reduce the cost of cardiac surgery and imrove efficiency. This change has been both financially sucessful and safe for patients. To allow for this success, a joint effort is required between the departments of cardiac surgery and anesthesiology involving the preoperative, intraoperative and postoperative treatment of these patients. Through recogition of suitable candidates, modifications in anesthetic techique, and appropriate postoperative management, the goal of extubation within 6 hours of admission to the cardiac recovery area can be achieved. Changes in intraoperative and early postoperative management of cardiac surgical patients are discussed. Specific recovery models are reviewed with disussion of the parallel and integrated models. Methods of preicting prolonged extubation times and intensive care unit length of stay are also discussed. Initial management of the cardiac patient in the cardiac recovery area is presented with a more in-depth review of specific complications: stroke, atril fibrillation, blood loss, left ventricular dysfunction, and pulonary dysfunction.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | - Davy Cheng
- Department of Anesthesia and Perioperative Medicine, St Josephs' Health Care, University of Western Ontario, London, Ontario, Canada
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Rodriguez-Blanco YF, Carvalho EMF, Gologorsky A, Lo K, Salerno TA, Gologorsky E. Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery. J Card Surg 2016; 31:274-81. [DOI: 10.1111/jocs.12736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Yiliam F. Rodriguez-Blanco
- Department of Anesthesiology; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami Florida
| | - Enisa M. F. Carvalho
- Department of Anesthesiology; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami Florida
| | | | - Kaming Lo
- Department of Biostatistics; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami Florida
| | - Tomas A. Salerno
- Department of Surgery; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami Florida
| | - Edward Gologorsky
- Department of Anesthesiology; Allegheny General Hospital; Pittsburgh Pennsylvania
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Borracci RA, Ochoa G, Ingino CA, Lebus JM, Grimaldi SV, Gambetta MX. Routine operation theatre extubation after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg 2016; 22:627-32. [PMID: 26826715 DOI: 10.1093/icvts/ivv409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/29/2015] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. METHODS A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. RESULTS Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). CONCLUSIONS OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.
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Affiliation(s)
- Raul A Borracci
- Department of Cardiac Surgery, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina School of Medicine, Buenos Aires University, Buenos Aires, Argentina
| | - Gustavo Ochoa
- Department of Anesthesia, and Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Carlos A Ingino
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Janina M Lebus
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Sabrina V Grimaldi
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria X Gambetta
- Department of Cardiology, ENERI-Sagrada Familia Clinic, Buenos Aires, Argentina
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Gutsche JT, Erickson L, Ghadimi K, Augoustides JG, Dimartino J, Szeto WY, Ochroch EA. Advancing Extubation Time for Cardiac Surgery Patients Using Lean Work Design. J Cardiothorac Vasc Anesth 2014; 28:1490-6. [DOI: 10.1053/j.jvca.2014.05.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Indexed: 11/11/2022]
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Badhwar V, Esper S, Brooks M, Mulukutla S, Hardison R, Mallios D, Chu D, Wei L, Subramaniam K. Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs. J Thorac Cardiovasc Surg 2014; 148:3101-9.e1. [DOI: 10.1016/j.jtcvs.2014.07.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 10/25/2022]
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18
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A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:468. [PMID: 25123092 PMCID: PMC4243831 DOI: 10.1186/s13054-014-0468-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/22/2014] [Indexed: 02/08/2023]
Abstract
Introduction Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end points in adult patients after elective cardiac surgery. Methods In a prospective, single-blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new-onset cardiac arrhythmia, low cardiac output syndrome, need for cardiopulmonary resuscitation, stroke, acute renal failure, and death. Results Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P <0.001). Median length of stay in the PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P <0.001). Of the adverse events examined, only the incidence of new-onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups. Conclusions Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step-down unit, without compromising patient safety. Trial registration ISRCTN71768341. Registered 11 March 2014.
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Calvache JA, Chaparro LE, Chaves A, Delgado MB, Fonseca N, Montes FR, Moyano JR, Rubio J. Estrategias y obstáculos para el desarrollo de la investigación en programas de anestesiología: documento de consenso en Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/j.rca.2012.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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20
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Calvache JA, Chaparro LE, Chaves A, Delgado MB, Fonseca N, Montes FR, Moyano JR, Rubio J. Strategies and obstacles to research development in anesthesiology programs: Consensus document in Colombia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/j.rcae.2012.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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21
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Rodriguez Blanco YF, Candiotti K, Gologorsky A, Tang F, Giquel J, Barron ME, Salerno TA, Gologorsky E. Factors Which Predict Safe Extubation in the Operating Room Following Cardiac Surgery. J Card Surg 2012; 27:275-80. [DOI: 10.1111/j.1540-8191.2012.01434.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Strategies and obstacles to research development in anesthesiology programs: Consensus document in Colombia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240040-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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23
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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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Outcome after valve surgery in octogenarians and efficacy of early mobilization with early cardiac rehabilitation. Gen Thorac Cardiovasc Surg 2010; 58:606-11. [DOI: 10.1007/s11748-010-0665-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 06/14/2010] [Indexed: 10/18/2022]
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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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Abstract
Fast track in cardiac surgery is not well defined. In the past early or immediate extubation was used as a marker. After cardiac surgery this parameter is not sufficient. In addition to cardiorespiratory stability, circulatory and haemostatic homeostasis are also required. Therefore the current Fast Track concept includes a period of intensive monitoring of the patient postoperatively to establish stability. Thereafter intensive care medicine should not be required. Evolving new surgical concepts in combination with appropriate anaesthesiologic management will lead to wide application of fast track cardiac surgery in the future.
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Byhahn C, Meininger D, Kessler P. [Coronary artery bypass grafting in conscious patients: a procedure with a perspective?]. Anaesthesist 2009; 57:1144-54. [PMID: 19015830 DOI: 10.1007/s00101-008-1479-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients undergoing coronary artery bypass grafting increasingly show severe co-morbidities, which can negatively affect the outcome. Recent developments in cardiac surgery have therefore focused on minimizing the invasiveness of the procedure by revascularization on the beating heart without cardiopulmonary bypass, and by reducing surgical trauma using smaller surgical incisions. Progress in minimally invasive cardiac surgery has led to minimally invasive anesthesia, i.e. using high thoracic epidural anesthesia as the sole technique in the conscious patient (awake coronary artery bypass grafting, ACAB). Published data on ACAB procedures in smaller cohorts have demonstrated that the procedure is safe. Significant complications occurred in 7.1% of patients. A particular cause of concern during ACAB surgery is the development of spinal epidural hematoma the risk of which has been estimated to be as high as 1:1,000. A thorough risk-benefit analysis has therefore to be made. Currently, ACAB surgery remains limited to few specialized centers and highly selected patients.
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Affiliation(s)
- C Byhahn
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum der JW Goethe-Universität, Frankfurt, Germany.
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Gooi J, Marasco S, Rowland M, Esmore D, Negri J, Pick A. Fast-track cardiac surgery: application in an Australian setting. Asian Cardiovasc Thorac Ann 2008; 15:139-43. [PMID: 17387197 DOI: 10.1177/021849230701500212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.
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Affiliation(s)
- Julian Gooi
- CJOB Cardiothoracic Department, Alfred Hospital, Melbourne, Australia.
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Kataoka G, Murai N, Kodera K, Sasaki A, Asano R, Ikeda M, Yamaguchi A, Takeuchi Y. Clinical experience with Smart Care after off-pump coronary artery bypass for early extubation. J Artif Organs 2007; 10:218-22. [DOI: 10.1007/s10047-007-0392-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 07/16/2007] [Indexed: 11/30/2022]
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Umenai T, Nakajima Y, Sessler DI, Taniguchi S, Yaku H, Mizobe T. Perioperative Amino Acid Infusion Improves Recovery and Shortens the Duration of Hospitalization After Off-Pump Coronary Artery Bypass Grafting. Anesth Analg 2006; 103:1386-93. [PMID: 17122208 DOI: 10.1213/01.ane.0000240972.84337.7c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative amino acid infusion helps maintain core temperature and improves patient outcomes after gynecologic and orthopedic surgery. In the present study we prospectively determined the effect of amino acid infusion on esophageal core temperature and postoperative outcomes during off-pump coronary artery bypass grafting (CABG). One-hundred-eighty consecutive patients undergoing primary elective or urgent off-pump CABG were randomly divided into two groups: the i.v. amino acid infusion group (4 kJ kg(-1) h(-1) starting 2 h before surgery) and the saline infusion group (similar period and volume of saline infusion). The esophageal core temperature at the end of surgery was 35.6 (35.3-35.8) degrees C [mean (95% confidence interval)] in the saline infusion group and 36.1 degrees C (35.9-36.3) degrees C in the amino acid infusion group (P = 0.01). Kaplan-Meier analysis demonstrated that patients given amino acids required a significantly shorter duration of postoperative mechanical ventilation than patients given saline [median (95% confidence interval), 3.0 (2.5-3.9) vs 4.5 (3.8-5.8) h; P = 0.01]. Furthermore, intensive care unit stay [20 (19.5-38.4) vs 44 (21-45) h; P = 0.001] and days until fit for discharge from hospital [10 (9-11) vs 12 (11-13) days; P = 0.004] were significantly shorter in patients given amino acid. Perioperative amino acid infusion in patients undergoing off-pump CABG effectively minimizes intraoperative hypothermia and improves postoperative recovery.
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Edgerton JR, Herbert MA, Prince SL, Horswell JL, Michelson L, Magee MJ, Dewey TM, Edgerton ZJ, Mack MJ. Reduced Atrial Fibrillation in Patients Immediately Extubated After Off-Pump Coronary Artery Bypass Grafting. Ann Thorac Surg 2006; 81:2121-6; discussion 2126-7. [PMID: 16731140 DOI: 10.1016/j.athoracsur.2006.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 12/21/2005] [Accepted: 01/03/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND We analyzed data from patients undergoing off-pump isolated coronary artery bypass grafting surgery (OPCABG) to determine if immediate extubation in the operating room affected the incidence of postoperative atrial fibrillation. METHODS The study group comprised 2,376 consecutive OPCABG patients operated on between January 1, 2000, and December 31, 2004, by 22 surgeons at 18 hospitals. The data were subjected to univariate, multivariate analysis of variance, and logistic analysis. Logistic regression of matched groups was used to eliminate the effect of some confounding variables. RESULTS Patients immediately extubated after surgery had a reduced incidence of atrial fibrillation (10.6% versus 18.5%; p < 0.001), shorter length of stay (4.8 +/- 3.5 versus 6.3 +/- 5.2 days; p < 0.001), and also reduced mortality (1.1% versus 2.4%; p = 0.04). Logistic analysis identified as significant factors for postoperative atrial fibrillation, postoperative ventilator usage (p < 0.001; odds ratio [OR] = 1.63; 95% confidence interval [CI]: 1.24 to 2.14), male sex (p = 0.002; OR = 1.51; 95% CI: 1.17 to 1.96), previous CABG (p = 0.005; OR = 0.43; 95% CI: 0.24 to 0.78). Congestive heart failure may also be a contributing factor. In patient groups matched for their risk of mortality, postoperative ventilator use (p < 0.001; OR = 1.80; 95% CI: 1.31 to 2.47), increasing age, and male sex were all statistically significant risk factors. When patient groups were matched on a combination of factors including preoperative beta-blocker usage, pulmonary disease, and smoking, postoperative ventilator use (p = 0.005; OR = 1.66; 95% CI: 1.16 to 2.38), along with increasing age, male sex, and previous CABG (reduced odds of atrial fibrillation developing) were statistically significant. CONCLUSIONS Immediate extubation after OPCABG appears to reduce the incidence of postoperative atrial fibrillation independent of comorbidities.
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Affiliation(s)
- James R Edgerton
- Cardiopulmonary Research Science and Technology Institute, Dallas, Texas, USA.
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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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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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Flynn M, Reddy S, Shepherd W, Holmes C, Armstrong D, Lunn C, Khan K, Kendall S. Fast-tracking revisited: routine cardiac surgical patients need minimal intensive care. Eur J Cardiothorac Surg 2004; 25:116-22. [PMID: 14690742 DOI: 10.1016/s1010-7940(03)00608-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Following cardiac surgery, patients are transferred from the operating theatre to intensive care. This clinical environment has one nurse per patient and facilities for mechanical ventilation. Patients are kept in this setting until the following day. This practice has been challenged with early extubation of patients. At our institution we have established a fast-track policy including the following features: (1) patient selection; (2) operating list scheduling with fast-track patients first; (3) anaesthetic tailored to early extubation; (4) methodical procedure with warm cardiopulmonary bypass; (5) removal of the arterial line; (6) transfer from intensive care to a separate high dependency unit ('step-down') on the day of operation, where the ratio of nurse to patient is one to three and there are no ventilatory facilities and no invasive monitoring; or (7) to keep these patients on ICU but decrease the nurse to patient ratio. METHOD The case notes of 572 patients who predominantly had myocardial revascularisation, undergoing this process from July 1996 to July 2000 at our institution were reviewed. RESULTS Mean EUROSCORE for the study group was 1.42. The 30-day mortality rate for the study group was 0.34%, mean intensive care time was 5 h 52 min, mean time to extubation was 3 h 10 min, mean readmission rate to intensive care was 0.34% and mean hospital stay from day of operation (inclusive) was 5.65 days. This process increased our throughput by 14.6% (compared to standard practices). COMMENT This study demonstrates that transfer of appropriate patients to a high dependency area from intensive care following cardiac surgery is safe. It allows intensive care beds to be used by more than one patient each day and allows significant cost savings by reducing the nursing ratio per patient.
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Affiliation(s)
- M Flynn
- Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK.
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Guller U, Anstrom KJ, Holman WL, Allman RM, Sansom M, Peterson ED. Outcomes of early extubation after bypass surgery in the elderly. Ann Thorac Surg 2004; 77:781-8. [PMID: 14992871 DOI: 10.1016/j.athoracsur.2003.09.059] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2003] [Indexed: 11/30/2022]
Abstract
BACKGROUND While early extubation after coronary artery bypass grafting (CABG) has been associated with resource savings, its effect on patient outcomes remains unclear. The goal of the present investigation was to evaluate whether early extubation can be performed safely in elderly CABG patients in community practice. METHODS We studied 6,446 CABG patients, aged 65 years and older, treated at 35 hospitals between 1995 and 1998. Patients were categorized based on their post-CABG extubation duration (early, < 6 hours; intermediate, 6 to < 12 hours; and late, 12 to 24 hours). We compared unadjusted and risk-adjusted mortality, reintubation rates, and post-CABG length of stay (pLOS). We also examined the association between patients' intubation time and outcomes among patients with similar propensity for early extubation and among high-risk patient subgroups. RESULTS The overall mean post-CABG intubation time was 9.8 (SD 5.7) hours with 29% of patients extubated within 6 hours. After adjusting for preoperative risk factors patients extubated in less than 6 hours had significantly shorter postoperative hospital stays than those with later extubation times. Patients extubated early also tended to have equal or better risk-adjusted mortality than those with intermediate (odds ratio: 1.69, p = 0.08) or long intubation times (odds ratio: 1.97, p = 0.02). These results were consistent among patients with similar preoperative propensity for early extubation and among important high-risk patient subgroups. There was no evidence for higher reintubation rates among elderly patients selected for early extubation. CONCLUSIONS In community practice, early extubation after CABG can be achieved safely in selected elderly patients. This practice was associated with shorter hospital stays without adverse impact on postoperative outcomes.
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Affiliation(s)
- Ulrich Guller
- Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama, USA
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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: 68] [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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Cammu G, De Keersmaecker K, Casselman F, Coddens J, Hendrickx J, Van Praet E, Deloof T. Implications of the use of neuromuscular transmission monitoring on immediate postoperative extubation in off-pump coronary artery bypass surgery. Eur J Anaesthesiol 2003; 20:884-90. [PMID: 14649340 DOI: 10.1017/s026502150300142x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE When continuous infusions of neuromuscular blocking drugs are administered during lengthy interventions and no routine antagonism of their effects is applied, there is a dramatic incidence of residual curarization. We have examined whether the use of neuromuscular transmission monitoring results in differences in the incidence of postoperative residual curarization, the use of antagonist agents, and the endotracheal extubation rate and outcome after continuous infusion of rocuronium in patients undergoing off-pump coronary artery bypass surgery. METHODS Twenty patients were assigned to group 1 (n = 10, non-blinded neuromuscular transmission monitoring) or group 2 (n = 10, blinded neuromuscular transmission monitoring). In group 1, patients were given rocuronium at an infusion rate of 6 microg kg(-1) min(-1). The rate was manually adjusted in order to maintain T1/T0 at 10%. In group 2, a rocuronium infusion was started 30 min after induction of anaesthesia, at a rate of 6 microg kg(-1) min(-1); this rate was left unchanged during surgery. The rocuronium infusion was discontinued on completion of all vascular anastomoses; propofol was stopped at the beginning of closure of the subcutis and pirinitramide (piritramide) 15 mg was administered intravenously. Remifentanil was discontinued at the beginning of skin closure and neostigmine (50 microg kg(-1)) administered at the end of surgery when the train-of-four ratio was < 0.9 in group 1, and routinely in group 2. A 20 min test period for spontaneous ventilation was allowed once surgery had been accomplished. When the train-of-four ratio was > or = 0.9 (group 1), patients were extubated if also breathing spontaneously, fully awake and able to follow commands. When they met the clinical criteria for normal neuromuscular function after induced blockade, patients in group 2 were extubated when fully awake and able to follow commands. RESULTS In group 1, the rate of rocuronium infusion required to keep T1/T0 at 10% was 5 +/- 1.9 microg kg(-1) min(-1); this was not significantly different from the fixed rate in group 2 (P = 0.15). One patient in group 2 was excluded. Eight out of 10 and eight out of nine patients in groups 1 and 2, respectively, reached the extubation criteria. Three out of eight, and five out of eight, patients from groups 1 and 2, respectively, were extubated in the operating room. At that time of endotracheal extubation, all three patients from group 1, but only four of the five patients from group 2 had a train-of-four ratio > or = 0.9. In group 2, one patient was reintubated in the intensive care unit. The incidence of pharmacological reversal was high in group 1. CONCLUSIONS Although we found no additional benefit of using neuromuscular transmission monitoring, it seems an absolute necessity for safety reasons. Pharmacological antagonism was mandatory. However, in our opinion, it is not wise routinely to perform immediate postoperative extubation in off-pump coronary artery bypass surgery.
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Affiliation(s)
- G Cammu
- Department of Anaesthesia and Critical Care Medicine, Onze-Lieve-Vrouw Clinic, Aalst, Belgium.
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Implications of the use of neuromuscular transmission monitoring on immediate postoperative extubation in off-pump coronary artery bypass surgery. Eur J Anaesthesiol 2003. [DOI: 10.1097/00003643-200311000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Montes FR, Giraldo JC, Betancur LA, Rincón JD, Rincón IE, Vanegas MV, Charris H. Endotracheal intubation with a lightwand or a laryngoscope results in similar hemodynamic variations in patients with coronary artery disease. Can J Anaesth 2003; 50:824-8. [PMID: 14525823 DOI: 10.1007/bf03019380] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To asses the cardiovascular changes after either lightwand or conventional laryngoscopic endotracheal intubation (EI) in patients with coronary artery disease. METHODS Following Institutional approval and informed consent, 80 consecutive patients undergoing elective coronary artery bypass grafting were enrolled in this prospective, controlled, single-blinded study. General anesthesia was induced with fentanyl 5 micro x kg(-1) and thiopental 5 mg x kg(-1) followed by pancuronium 0.1 mg x kg(-1). After loss-of-eyelash reflex the lungs were manually ventilated with 2% isoflurane in oxygen for five minutes. Patients were then randomly allocated to receive either the lightwand (lightwand group, n = 41) or direct-vision laryngoscopy (laryngoscopy group, n = 39). Heart rate (HR) and direct blood pressure were recorded before induction, after induction but before EI, during EI, immediately after EI and at ten-second intervals for the following five minutes. Hemodynamic management during induction was standardized. Hypotension was treated with volume replacement, ephedrine, or phenylephrine as indicated; hypertension was treated with iv nitroglycerin; tachycardia was treated with boluses of esmolol; and, bradycardia was treated with atropine or ephedrine. RESULTS In both groups, mean arterial blood pressures and HR increased significantly after EI. There was a tendency for the lightwand group to have lower arterial blood pressures and slower HR. However, the differences between the two groups did not reach statistical significance. Requirements for drugs to control HR and mean arterial pressure were similar in both groups. CONCLUSION In patients with coronary artery disease using a lightwand intubation technique does not modify the hemodynamic response associated with EI as compared with standard direct-vision laryngoscopy.
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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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Cassina T, Chioléro R, Mauri R, Revelly JP. Clinical experience with adaptive support ventilation for fast-track cardiac surgery. J Cardiothorac Vasc Anesth 2003; 17:571-5. [PMID: 14579209 DOI: 10.1016/s1053-0770(03)00199-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate adaptive support ventilation (ASV), an automatic microprocessor-controlled mode of mechanical ventilation, for the initial ventilatory management in consecutive patients eligible for early extubation after cardiac surgery. DESIGN Prospective observational study. SETTING Nonuniversity cardiac center. PARTICIPANTS One hundred fifty-five consecutive patients eligible for early tracheal extubation after cardiac surgery. INTERVENTIONS On intensive care unit arrival, patients were ventilated by adaptive support ventilation. This mode provided an automatic selection of initial ventilatory parameters and a continuous adaptation to patient's respiratory activity, guaranteeing that a preset minute ventilation was delivered. Once the patients had recovered sustained spontaneous ventilation, the ventilator was switched manually to pressure support for the terminal part of respiratory weaning followed by extubation. MEASUREMENTS AND MAIN RESULTS In adaptive support ventilation, all patients could be ventilated satisfactorily except 1; tidal volume was 8.7 +/- 1.4 mL/kg of ideal body weight (mean +/- SD), plateau pressure was 20.3 +/- 3.9 cmH(2)O, and arterial blood gas measurements were satisfactory. One hundred thirty-four patients (86%) were extubated within 6 hours, and intubation time was 3.6 (2.53-4.83) hours (median, [quartiles]). No reintubation because of respiratory failure was required. Adaptive support ventilation was considered easy to use by both the nurses and physicians. CONCLUSIONS Adaptive support ventilation was used in a group of 155 consecutive patients after fast-track cardiac surgery. This ventilation mode was safe, easy to apply, and allowed rapid extubation in suitable patients. ASV may facilitate postoperative respiratory management.
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Affiliation(s)
- Tiziano Cassina
- Anaesthesia/Intensive Care Unit, Department of Carsiovascular Ticino, Lugano, Switzerland
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Hansen LN, Ravn JB, Yndgaard S. Early extubation after single-lung transplantation: analysis of the first 106 cases. J Cardiothorac Vasc Anesth 2003; 17:36-9. [PMID: 12635058 DOI: 10.1053/jcan.2003.7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To determine if a modern anesthetic approach permits extubation immediately after surgery for single-lung transplantation. DESIGN A retrospective study of all patients undergoing single-lung transplantation from June 1993 to December 1999 in Denmark. SETTING Rigshospitalet, Copenhagen University hospital. PARTICIPANTS One hundred six consecutive patients scheduled for single-lung transplantation. INTERVENTIONS From July 1997, the anesthetic approach was changed to facilitate early extubation. The changes included epidural analgesia and short-acting anesthetic drugs. MEASUREMENTS AND MAIN RESULTS One hundred six patients were anesthetized for single-lung transplantation. The first 33 patients were moved to the intensive care unit for postoperative mechanical ventilation. After the change of anesthesia technique, 53 of 73 patients were extubated in the operating room. Eleven patients needed reintubation within the first 24 hours because of respiratory insufficiency, pulmonary edema, hemorrhage, or pneumothorax. The need for reintubation increased the length of stay in the intensive care unit by 1 day from 2 to 3 days (NS). The possibility of early extubation or the need for reintubation was not related to age, weight, sex, preoperative condition, mode of transport of the graft, duration of graft ischemia, or side of transplantation. CONCLUSION This study has shown that it is possible to extubate patients in the operating room immediately after single-lung transplantation in the majority of cases.
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Affiliation(s)
- Lise Nørrekjaer Hansen
- Department of Cardiothoracic Anesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark.
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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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Abstract
BACKGROUND Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays. OBJECTIVES To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL)(issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE(January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair). DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted. MAIN RESULTS Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively). REVIEWER'S CONCLUSIONS There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups. Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.
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Affiliation(s)
- C A Hawkes
- OCHRAD, School of Health Care, Oxford Brookes University, 44 London Road, Headington, Oxford, Oxfordshire, UK, OX3 7PD
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Kessler P, Neidhart G, Bremerich DH, Aybek T, Dogan S, Lischke V, Byhahn C. High Thoracic Epidural Anesthesia for Coronary Artery Bypass Grafting Using Two Different Surgical Approaches in Conscious Patients. Anesth Analg 2002. [DOI: 10.1213/00000539-200210000-00002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kessler P, Neidhart G, Bremerich DH, Aybek T, Dogan S, Lischke V, Byhahn C. High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients. Anesth Analg 2002; 95:791-7, table of contents. [PMID: 12351247 DOI: 10.1097/00000539-200210000-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique; n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique; n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 micro g/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%-15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (B(OPCAB), 95 +/- 11; CA(OPCAB), 68 +/- 9; B(MIDCAB), 86 +/- 10; CA(MIDCAB), 73 +/- 10; P not significant between groups). PaCO(2) increased from 42 +/- 2 mm Hg to 46 +/- 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as "good" or "excellent." In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts. IMPLICATIONS. The sole use of high thoracic epidural anesthesia was studied in 20 patients who underwent beating-heart coronary artery bypass grafting using either median or partial lower sternotomy while awake.
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Affiliation(s)
- Paul Kessler
- Department of Anesthesiology, J. W. Goethe University Hospital Center, Frankfurt, Germany.
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Royse C, Soeding P, Royse A. Immediate or early extubation: where do we start? Anesth Analg 2001; 92:1073-4. [PMID: 11273955 DOI: 10.1097/00000539-200104000-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Immediate or Early Extubation: Where Do We Start? Anesth Analg 2001. [DOI: 10.1097/00000539-200104000-00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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