Risk factor analysis for fast track protocol failure

Feasibility of deescalating postoperative care in enhanced recovery after cardiac surgery

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.

Operating Room Versus Intensive Care Unit Extubation Within 6 Hours After On-Pump Cardiac Surgery: Early Results and Hospital Costs

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.

Factors associated with an unsuccessful Fast-Track course following Minimally Invasive Surgical Mitral Valve Repair

OBJECTIVES

Analyses of fast-track processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery.

METHODS

Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of fast-track failure consisted of > 10 hours mechanical ventilation, >24 hours intensive care unit stay, re-intubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with fast-track failure.

RESULTS

In total, 491 patients were included in the study and were analysed. Two-hundred and thirty-seven patients (48.3%) failed the fast-track protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥3 (OR 2.05; CI 1.38-3.08; p < 0.001, pre-existing chronic kidney disease (OR 2.03; CI 1.14-3.70; p = 0.018), coronary artery disease (OR 1.90; CI 1.13-3.23; p = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; CI 2.81-36.01; p < 0.001) and procedure time (OR 1.01; CI 1.01-1.01; p < 0.001) were independently associated with fast-track failure.

CONCLUSIONS

Factors associated with fast-track failure in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed fast-track.

CLINICAL REGISTRATION NUMBER

The corresponding local ethics committee (Charité Medical School, Berlin, Germany) approved the present study which complies with the Declaration of Helsinki (ethics approval number: EA2/175/20).

Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up

OBJECTIVES

An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure.

DESIGN

A retrospective cohort study.

SETTING

A single academic center.

PARTICIPANTS

Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019.

INTERVENTION

The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients.

MEASUREMENTS AND MAIN RESULTS

Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve = 0.676; 95% confidence interval, 0.611-0.741).

CONCLUSION

Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.

Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative

Objective

Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure.

Results

We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).

Early Extubation in Enhanced Recovery from Cardiac Surgery

Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.

Early Discharge From Intensive Care After Cardiac Surgery is Feasible With an Adequate Fast Track, Stepdown Unit: Waikato Experience

BACKGROUND

Enhanced recovery programs within cardiothoracic surgery are a well described benefit to patient postoperative outcomes. We describe our Australasian unit's experience of a day zero discharge enhanced recovery unit from the intensive care department.

METHODS

A retrospective study was conducted on a prospectively maintained database at Waikato Cardiothoracic Unit from September 2014 till October 2017 with 1,739 patients undergoing cardiac surgery. Twenty-two (22) patients were excluded as deaths either intraoperative or in the intensive care unit (ICU) and therefore never discharged. Total population of the study was 1,717 patients. The primary endpoint of this study was to determine if there is no survival disadvantage for the day zero discharge unit compared to standard treatment in ICU at follow-up. The secondary endpoint of the study was to highlight the association between pre and postoperative variables and the impact on discharge from the ICU.

RESULTS

One hundred sixty-eight (168) patients were discharged to the enhanced recovery unit (ERU) day zero. Mean number of hours spent in ICU for the day zero cohort was 7.18 (±1.59. Mean Age 62.5 (±11.22), M:F 4.25:1. Patients were more likely to be discharged day zero if they had a lower EuroSCORE II 1.57 (±1.67) and lower preoperative creatinine 89.4 (±27.5). Those admitted to the ERU on day zero postoperatively were more likely to be discharged with a lower creatinine level, a higher haemoglobin level and have less readmissions per 30days (p<0.05). Survival analysis demonstrated that the patients who were discharged early from ICU had significantly better follow-up survival compared to those who were discharged after 24hours (p<0.05).

CONCLUSIONS

A fast track unit increases the efficiency of an ICU and cardiac surgical department. With the advancements of cardiac surgery a higher number of patients will be suitable for a fast track method. Our unit has demonstrated that a day zero fast track unit in New Zealand can perform with adequate patient safety with no increased risk of mortality and with low rates of failure of the day zero discharge fast track therapy.

Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial

BACKGROUND

The use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery.

METHODS

This clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients' depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented.

RESULTS

Demographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001).

CONCLUSIONS

Combined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.

Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients

This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.

Preoperative risk factors for unexpected postoperative intensive care unit admission: A retrospective case analysis

INTRODUCTION

The purpose of this retrospective case-control study was to investigate preoperative risk factors for unexpected postoperative intensive care unit (ICU) admissions in patients undergoing non-emergent surgical procedures in a tertiary medical centre.

METHODS

A medical record review of adult patients undergoing elective non-cardiac and non-transplant major surgical procedures during the period of January 2011 through December 2015 in the operating rooms of a large university hospital was carried out. The primary outcome assessed was unexpected ICU admission, with mortality as a secondary outcome. Demographic data, length of hospital and ICU stay and preoperative comorbidities were also obtained as exposure variables. Propensity score matching was then employed to yield a study and control group.

RESULTS

The group of patients who met inclusion criteria in the study and the control group that did not require ICU admission were obtained, each containing 1191 patients after propensity matching. Patients with acute and/or chronic kidney injury (odds ratio (OR) 2.20 [1.75-2.76]), valvular heart disease (OR: 1.94 [1.33-2.85]), peripheral vascular disease (PVD) (OR: 1.41 [1.02-1.94]) and congestive heart failure (CHF) (OR: 1.80 [1.31-2.46]) were all associated with increased unexpected ICU admission. History of cerebrovascular accident (CVA) (OR: 3.03 [1.31-7.01]) and acute and/or chronic kidney injury (OR: 1.62 [1.12-2.35]) were associated with increased mortality in all patients; CVA was also associated with increased mortality (OR: 3.15 [1.21-8.20]) specifically in the ICU population.

CONCLUSIONS

CHF, acute/chronic kidney injury, PVD and valve disease were significantly associated with increased unexpected ICU admission; patients with CVA suffered increased mortality when admitted to the ICU.

Association of Oral Intake and Transient Mixed Venous Oxygen Desaturation in Patients Undergoing Fast-Track Postoperative Care After Open-Heart Surgery

OBJECTIVE

The impact of early resumption of oral intake after cardiac surgery on hemodynamics has not been characterized. The authors examined the effects of early oral intake on the oxygen supply-demand relationship in patients undergoing on-pump cardiac surgery in an early recovery after surgery program.

DESIGN

Prospective data were collected in postcardiac surgical patients in a multidisciplinary intensive care unit (ICU) during an 18-month period.

SETTING

Single institution study.

PARTICIPANTS

Forty-three patients who underwent either mitral or aortic valve repair and were successfully liberated from ventilatory support within 10 hours after surgery.

INTERVENTIONS

Patients were either allowed to resume oral intake on the morning of the first postoperative day or not at the discretion of the surgical team after extubation.

MEASUREMENTS AND MAIN RESULTS

The oxygen supply-demand relationship was assessed continuously with cardiac index and mixed venous oxygen saturation (SvO₂). Among the subjects, 22 patients were allowed to eat, and transient SvO₂ decrease was noted in 13 patients. All transient SvO₂ decreases occurred in the patients with early oral intake. The hemodynamic status and oxygen supply-demand relationship did not differ between the patients with and without transient SvO₂ decrease. All the subjects were discharged successfully from the ICU on the first postoperative day, and the length of hospital stay was similar irrespective of SvO₂ decrease after early oral intake.

CONCLUSIONS

Early oral intake shortly after extubation was associated with transient but significant SvO₂ decrease in patients who underwent fast-track recovery after open-heart surgery. Because this phenomenon did not negatively affect the postoperative outcome, early oral intake may not be harmful.

Effect of motor subtypes of delirium in the intensive care unit on fast-track failure after cardiac surgery

OBJECTIVE

The purpose of the study was to evaluate the association between motor subtypes of postoperative delirium in the intensive care unit and fast-track failure (a composite outcome of prolonged stay in the intensive care unit >48 hours, intensive care unit readmission, and 30-day mortality) after cardiac surgery.

METHODS

This was a secondary analysis of a prospective cohort study of 600 consecutive adults undergoing cardiac surgery at a university hospital in Hong Kong (July 2013 to July 2015). The motor subtypes of delirium were classified using the Richmond Agitation Sedation Score and Confusion Assessment Method intensive care unit assessments performed by trained bedside nurses. A generalized estimating equation was used to estimate a common relative risk of fast-track failure associated with motor subtypes.

RESULTS

The incidences of hypoactive, hyperactive, and mixed motor subtypes were 4.3% (n = 26), 4.0% (n = 24), and 5.5% (n = 33), respectively. Fast-track failure occurred in 88 patients (14.7%). There was an association between delirium (all subtypes) and fast-track failure (P = .048); hyperactive delirium (relative risk, 1.95; 95% confidence interval, 0.96-3.94); hypoactive delirium (relative risk, 2.79; 95% confidence interval, 1.34-5.84); and mixed delirium (relative risk, 2.55; 95% confidence interval, 1.11-5.88). Hypoactive and mixed subtypes were associated with prolonged intensive care unit stay (both P = .001).

CONCLUSIONS

Patients with pure hypoactive delirium had a similar risk of developing fast-track failure as other motor subtypes. Differentiation of motor subtypes is unlikely to be clinically important for prognostication of fast-track failure. However, because delirium is associated with poor outcomes, potential treatment strategies should address all subtypes equally.

Prognostic value of procalcitonin in patients after elective cardiac surgery: a prospective cohort study

Background

Procalcitonin (PCT) is a well-known prognostic marker after elective cardiac surgery. However, the impact of elevated PCT in patients with an initially uneventful postoperative course is still unclear. The aim of this study was to evaluate PCT levels as a prognostic tool for delayed complications after elective cardiac surgery.

Methods

A prospective study was performed in 751 patients with an apparently uneventful postoperative course within the first 24 h after elective cardiac surgery. Serum PCT concentration was taken the morning after surgery. All patients were screened for the occurrence of delayed complications. Delayed complications were defined by in-hospital death, intensive care unit readmission, or prolonged length of hospital stay (>12 days). Odds ratios (OR) [with 95% confidence interval (CI)] were calculated by logistic regression analyses and adjusted for confounders. Predictive capacity of PCT for delayed complications was calculated by ROC analyses. The cutoff value of PCT was derived from the Youden Index calculation.

Results

Among 751 patients with an initially uneventful postoperative course, 117 patients developed delayed complications. Serum PCT levels the first postoperative day were significantly higher in these 117 patients (8.9 ng/ml) compared to the remaining 634 (0.9 ng/ml; p < 0.001). ROC analyses showed that PCT had a high accuracy to predict delayed complications (optimal cutoff value of 2.95 ng/ml, AUC of 0.90, sensitivity 73% and specificity 97%). Patients with PCT levels above 2.95 ng/ml the first postoperative day had a highly increased risk of delayed complications (adjusted OR, 110.2; 95% CI 51.5–235.5; p < 0.001).

Conclusions

A single measurement of PCT seems to be a useful tool to identify patients at risk of delayed complications despite an initially uneventful postoperative course.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation after surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016.

OBJECTIVES

To determine the safety and effectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (January 2012 to May 2015), Embase (January 2012 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2012 to May 2015) and the Institute for Scientific Information (ISI) Web of Science (January 2012 to May 2015), along with reference lists of articles, to identify additional trials. We applied no language restrictions.

SELECTION CRITERIA

We included all randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups. We focused on the following fast-track interventions, which were designed for early extubation after surgery: administration of low-dose opioid-based general anaesthesia during cardiac surgery and use of a time-directed extubation protocol after surgery. The primary outcome was risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted study data. We contacted study authors for additional information. We calculated a Peto odds ratio (OR) for risk of mortality and used a random-effects model to report risk ratio (RR), mean difference (MD) and 95% confidence intervals (95% CIs) for all secondary outcomes.

MAIN RESULTS

We included 28 trials (4438 participants) in the updated review. We considered most participants to be at low to moderate risk of death after surgery. We assessed two studies as having low risk of bias and 11 studies high risk of bias. Investigators reported no differences in risk of mortality within the first year after surgery between low-dose versus high-dose opioid-based general anaesthesia groups (OR 0.53, 95% CI 0.25 to 1.12; eight trials, 1994 participants, low level of evidence) and between a time-directed extubation protocol versus usual care (OR 0.80, 95% CI 0.45 to 1.45; 10 trials, 1802 participants, low level of evidence).Researchers noted no significant differences between low-dose and high-dose opioid-based anaesthesia groups in the following postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99; eight trials, 1683 participants, low level of evidence), stroke (RR 1.17, 95% CI 0.36 to 3.78; five trials, 562 participants, low level of evidence) and tracheal reintubation (RR 1.77, 95% CI 0.38 to 8.27; five trials, 594 participants, low level of evidence).Comparisons with usual care revealed no significant differences in the risk of postoperative complications associated with a time-directed extubation protocol: myocardial infarction (RR 0.59, 95% CI 0.27 to 1.31; eight trials, 1378 participants, low level of evidence), stroke (RR 0.85, 95% CI 0.33 to 2.16; 11 trials, 1646 participants, low level of evidence) and tracheal reintubation (RR 1.34, 95% CI 0.74 to 2.41; 12 trials, 1261 participants, low level of evidence).Although levels of heterogeneity were high, low-dose opioid anaesthesia was associated with reduced time to extubation (reduction of 4.3 to 10.5 hours, 14 trials, 2486 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 0.4 to 7.0 hours, 12 trials, 1394 participants, low level of evidence). Use of a time-directed extubation protocol was associated with reduced time to extubation (reduction of 3.7 to 8.8 hours, 16 trials, 2024 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 3.9 to 10.5 hours, 13 trials, 1888 participants, low level of evidence). However, these two fast-track care interventions were not associated with reduced total length of stay in the hospital (low level of evidence).

AUTHORS' CONCLUSIONS

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

Comparison of the single-lumen endotracheal tube and double-lumen endobronchial tube used in minimally invasive cardiac surgery for the fast track protocol

BACKGROUND

Minimally invasive cardiac surgery (MICS) has been more commonly performed due to the reduced amount of bleeding and transfusion and length of hospital stay. We investigated the feasibility of performing MICS using single-lumen endotracheal tube (SLT).

METHODS

We conducted a retrospective review of clinical data of 112 patients who underwent MICS between July 2012 and March 2015. The patients underwent MICS using a SLT or a double lumen endotracheal tube (DLT). The duration of intensive care unit (ICU) stay and mechanical ventilation were recorded and analyzed.

RESULTS

Of the 96 patients, 50 were intubated with a SLT and 46 were intubated with a DLT. Anesthetic induction to skin incision time, surgical time and total anesthetic time were significant decreased in the SLT group (P<0.05). However, there was no difference in the duration of ICU stay and mechanical ventilation, and the incidence of extubation in operation room between the two groups.

CONCLUSIONS

Comparing with insertion of a SLT, insertion of a DLT provided equivalent duration of ICU stay and mechanical ventilation after the MICS. Therefore, the type of inserted endotracheal tube would not influence on failure of the fast track protocol and insertion of a SLT is feasible and could be an alternative method to a DLT.

Fast-Tracking Colostomy Closures

There have been very few studies on applying fast-track principles to colostomy closures. We believe that outcome may be significantly improved with multimodal interventions in the peri-operative care of patients undergoing this procedure. A retrospective study was carried out comparing patients who had undergone colostomy closures by the fast-track and traditional care protocols at our centre. We intended to analyse peri-operative period and recovery in colostomy closures to confirm that fast-track surgery principles improved outcomes. Twenty-six patients in the fast-track arm and 24 patients in the traditional care arm had undergone colostomy closures. Both groups were comparable in terms of their baseline parameters. Patients in the fast-track group were ambulatory and accepted oral feeding earlier. There was a significant reduction in the duration of stay (4.73 ± 1.43 days vs. 7.21 ± 1.38 days, p = 0.0000). We did not observe a rise in complications or 30-day re-admissions. Fast-track surgery can safely be applied to colostomy closures. It shows earlier ambulation and reduction in length of hospital stay.

Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit

PURPOSE

To investigate factors associated with unplanned postoperative admissions to the intensive care unit (ICU).

METHODS

Data from the National Anesthesia Clinical Outcomes Registry (NACOR) were analyzed. We performed univariate and multivariate logistic regression to identify patient- and surgery-specific characteristics associated with unplanned postoperative ICU admission. We also recorded the prevalence of Current Procedural Terminology (CPT) and International Classification of Diseases, ninth revision ( ICD-9) billing codes and outcomes for unplanned postoperative ICU admissions.

RESULTS

Of 23 341 130 records in the database, 2 910 738 records met our inclusion criteria. A higher American Society of Anesthesiologists physical status (ASA PS) class, case duration greater than 4 hours, and advanced age were associated with a greater likelihood of unplanned ICU admission. Vascular and thoracic surgery patients were more likely to have an unplanned ICU admission. The most common CPT and ICD-9 codes involved repair of femur/hip fracture, bowel resection, and acute postoperative pain. Large community hospitals were more likely than university hospitals to have unplanned postoperative ICU admissions. Patients in the unplanned postoperative ICU admission group were more likely to have experienced intraoperative cardiac arrest, hemodynamic instability, or respiratory failure and were more likely to die in the immediate perioperative period.

CONCLUSION

Our study is the first diverse analysis of unplanned postoperative ICU admissions in the literature across multiple specialties and practice models. We found an association of advanced age, higher ASA PS class, and duration of procedure with unplanned ICU admission after surgery. Surgical specialties and procedures with the most unplanned ICU admissions could be areas for quality improvement and clinical pathways in the future.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Impact of fast-track discharge from cardiothoracic intensive care on family satisfaction

Background

Dissatisfaction with the intensive care unit may threaten medical care. Clarifying treatment preferences can be useful in these settings, where physician direction may influence decision making and therefore medical treatment. This study aimed to evaluate whether fast-track discharge from intensive care units affects the satisfaction of family members.

Methods

We used a single-center non-randomized trial, with all eligible family members involved. To evaluate family satisfaction, we used the Society of Critical Care Family Needs Assessment questionnaire (SCCMFNAQ). We hypothesized that those discharged within 24 h of intensive care unit admission and their families would have higher levels of satisfaction. Patients were scored using the therapeutic interventions scoring system (TISS) and additive EuroSCORE.

Results

Two-hundred fifty-five family members were enrolled. The mean patient age was 53 years, and 92 % were male. The median satisfaction level among family members was 17.9 (range 14–31). Patients were divided into two groups, one receiving fast-track discharge (116 patients), and one whose members stayed longer (139 patients). The overall satisfaction was affected significantly by quality of the delivered care and dissatisfaction increased by lack of comfort in hospital settings, including the waiting room. No significant differences were seen between the two groups for overall satisfaction (p = 0.546) and individual components of the questionnaire. Higher satisfaction was linked to higher levels of education among family members (p = 0.045) and information being relayed by a senior physician p = 0.03 (two-tailed test).

Conclusions

Fast-track discharge from intensive care did not influence family satisfaction as hypothesized. Satisfaction relied on family members’ level of education and the level of seniority of the physician relaying information.

Readmission To Intensive Care Unit After Coronary Bypass Operations in the Short Term

OBJECTIVE

Intensive care unit (ICU) readmissions after coronary bypass (CABG) operations occur in a significant number of patients, and the prognosis is poor. We analyzed the risk factors for ICU readmissions after CABG operations.

METHODS

We retrospectively analyzed the prospectively collected data of 679 coronary bypass patients operated in a single institution in order to evaluate the risk factors for readmittance to the ICU with logistic regression analysis. The outcome results of patients readmitted to the ICU (Group R) and others (Group N) were compared.

RESULTS

Thirty-six (5.3%) patients were readmitted to the ICU. Postoperative in-hospital mortality and pulmonary and neurologic morbidity occurred in 43 (6.3%), 135 (19.9%), and 46 (6.8%) patients, respectively. The comparison of groups showed that mortality and morbidity were significantly higher in Group R compared to Group N (mortality 16.7% vs. 5.9, p=0.029; pulmonary morbidity 66.7% vs. 17.3%, p=0.0001; neurologic morbidity 38.9% vs. 5.0%, p=0.0001). Features associated with readmission included presence of left ventricular dysfunction preoperatively[odds ratio (OR)=4.1; 95% confidence interval (CI)=1.4-12.5; p=0.013], advanced NYHA Class (OR=5.3; 95% CI=1.3-21.7; p=0.022), pulmonary complications (OR=7.3; 95% CI=2.1-25.5; p=0.002), and neurologic complications (OR=4.6; 95% CI=1.3-16.7; p=0.021).

CONCLUSION

Patients readmitted to the ICU postoperatively have higher rates of mortality and pulmonary and neurologic morbidity after coronary bypass operations. Left ventricular dysfunction, advanced NYHA class, and postoperative pulmonary and neurologic complications are significant risk factors for readmission to the ICU.