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Özçobanoğlu S, Gündüz E, Tekerek NÜ. Comparison of ultrafast and fast track extubation after secundum atrial septal defect surgery in pediatric age group. Acta Chir Belg 2024; 124:217-222. [PMID: 37937527 DOI: 10.1080/00015458.2023.2281097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/03/2023] [Indexed: 11/17/2023]
Abstract
BACGROUND Patients who underwent ultrafast track on the operating table and fast track extubation in the pediatric intensive care unit for 2 to 6 h after secundum atrial septal defect surgery in the pediatric age group were compared. METHODS Between January 2013 and February 2017, 60 pediatric patients (24 boys, 36 girls; Mean age 7.5 ± 4.6 years) whose secundum atrial defect was closed were retrospectively analyzed. The patients were separated as those who were extubated on the operating table (Group1,n = 28) and those extubated in the pediatric intensive care unit within 2-6 h postoperatively (Group2,n = 32). RESULTS No difference was found in demographic data and preoperative catheter information between the groups. Cardiopulmonary bypass time was 20(18-25)/27.5(20-30)minutes (p:0.001), the cross-clamp time was 10(10-15)/15(11-20)minutes(p:0.004), the postoperative drainage amount was 50(25-50)/60(32.5-100)ml(p:0.013), the length of stay in the intensive care unit was 1(1--1)/1(1-2)day(p:0.025), the length of stay after intensive care was 3(2-3)/3(3-4)days(p:0.001) and the total hospital stay was 4(3-4)/5(4-5.5) days (p < 0.001), which were respectively shorter for the group 1 compared to 2. Postoperative blood product replacement, positive inotrope support, pericardial effusion, mortality, and morbidity were not detected in either groups. CONCLUSION In this study, it was observed that the UFT extubation was safe for the patients who were operated for secundum ASD, in the pediatric age group, and had a cross-clamp time not exceeding 15 min. It was found that the amount of drainage, length of stay in the intensive care unit, post-intensive care unit, and the total hospital stay of patients extubated on the operating table were shorter.
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Affiliation(s)
- Salih Özçobanoğlu
- Department of Cardiovascular Surgery, Akdeniz University, Antalya, Turkey
| | - Emel Gündüz
- Department of Anesthesiology and Reanimation, Akdeniz University, Antalya, Turkey
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2
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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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James L, Smith DE, Galloway AC, Paone D, Allison M, Shrivastava S, Vaynblat M, Swistel DG, Loulmet DF, Grossi EA, Williams MR, Zias E. Routine Extubation in the Operating Room After Isolated Coronary Artery Bypass. Ann Thorac Surg 2024; 117:87-94. [PMID: 37806334 DOI: 10.1016/j.athoracsur.2023.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). METHODS The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. RESULTS Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). CONCLUSIONS Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.
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Affiliation(s)
- Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Aubrey C Galloway
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York.
| | - Darien Paone
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Michael Allison
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | | | - Mikhail Vaynblat
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Daniel G Swistel
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Didier F Loulmet
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Eugene A Grossi
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Mathew R Williams
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Elias Zias
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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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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Recco D, Kaul S, Doherty M, McDougal D, Mahmood F, Khabbaz KR. Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00192-1. [PMID: 37080843 DOI: 10.1053/j.jvca.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes. DESIGN A retrospective cohort study. SETTING At a university hospital. PARTICIPANTS Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016. INTERVENTIONS An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016. MEASUREMENTS AND MAIN RESULTS The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant. CONCLUSIONS The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.
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Affiliation(s)
- Dominic Recco
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sumedh Kaul
- Department of Surgery, FIRST Program, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michelle Doherty
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Dawn McDougal
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care & Pain Medicine, Division of Cardiac Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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6
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Haunschild J, van Kampen A, Misfeld M, Von Aspern K, Ender J, Zakhary W, Borger MA, Etz CD. Is perioperative fast-track management the future of proximal aortic repair? EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6947988. [PMID: 36538944 DOI: 10.1093/ejcts/ezac578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 02/11/2023]
Abstract
OBJECTIVES The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Antonia van Kampen
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Martin Misfeld
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Institute of Academic Surgery, RPAH, Sydney, NSW, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | | | - Jörg Ender
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Waseem Zakhary
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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7
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Van Praet KM, Kofler M, Hirsch S, Akansel S, Hommel M, Sündermann SH, Meyer A, Jacobs S, Falk V, Kempfert J. Factors associated with an unsuccessful Fast-Track course following Minimally Invasive Surgical Mitral Valve Repair. Eur J Cardiothorac Surg 2022; 62:6693624. [PMID: 36069638 DOI: 10.1093/ejcts/ezac451] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Analyses of fast-track processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery. METHODS Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of fast-track failure consisted of > 10 hours mechanical ventilation, >24 hours intensive care unit stay, re-intubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with fast-track failure. RESULTS In total, 491 patients were included in the study and were analysed. Two-hundred and thirty-seven patients (48.3%) failed the fast-track protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥3 (OR 2.05; CI 1.38-3.08; p < 0.001, pre-existing chronic kidney disease (OR 2.03; CI 1.14-3.70; p = 0.018), coronary artery disease (OR 1.90; CI 1.13-3.23; p = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; CI 2.81-36.01; p < 0.001) and procedure time (OR 1.01; CI 1.01-1.01; p < 0.001) were independently associated with fast-track failure. CONCLUSIONS Factors associated with fast-track failure in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed fast-track. CLINICAL REGISTRATION NUMBER The corresponding local ethics committee (Charité Medical School, Berlin, Germany) approved the present study which complies with the Declaration of Helsinki (ethics approval number: EA2/175/20).
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Affiliation(s)
- Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Solveig Hirsch
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Serdar Akansel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matthias Hommel
- Institute for Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
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8
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Spanjersberg AJ, Ottervanger JP, Nierich AP, Hoogendoorn M, Bruinsma GJBB. Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta? J Cardiothorac Vasc Anesth 2022; 36:2954-2960. [PMID: 35288024 DOI: 10.1053/j.jvca.2022.01.047] [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: 11/17/2021] [Revised: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome. DESIGN A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio. SETTING At Isala Zwolle (NL), a large, nonacademic teaching hospital. PARTICIPANTS All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries. INTERVENTIONS The adaptation of surgical handling of the ascending aorta. MEASUREMENTS AND MAIN RESULTS In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79). CONCLUSIONS The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.
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Affiliation(s)
- Alexander J Spanjersberg
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands.
| | | | - Arno P Nierich
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
| | - Marga Hoogendoorn
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
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9
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Martin S, Jackson K, Anton J, Tolpin DA. Pro: Early Extubation (<1 Hour) After Cardiac Surgery Is a Useful, Safe, and Cost-Effective Method in Select Patient Populations. J Cardiothorac Vasc Anesth 2022; 36:1487-1490. [PMID: 35033437 DOI: 10.1053/j.jvca.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Simon Martin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX.
| | - Kirk Jackson
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - James Anton
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - Daniel A Tolpin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
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10
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Holaubek C, Winter F, Lesjak A, Aliabadi-Zuckermann A, Opfermann P, Urbanek B, Schlömmer C, Mouhieddine M, Zuckermann A, Steinlechner B. Perioperative Risk Factors for Intensive Care Unit Readmissions and Mortality After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:2339-2343. [PMID: 34879925 DOI: 10.1053/j.jvca.2021.10.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to identify perioperative risk factors associated with intensive care unit readmission and in-hospital death after cardiac surgery. DESIGN Retrospective analysis using a multivariate regression model to identify independent risk factors for intensive care unit [ICU] readmission and in-hospital mortality. SETTING The study was carried out in a single tertiary-care hospital. PARTICIPANTS This was an analysis of 2,789 adult patients. INTERVENTIONS All patients underwent cardiac surgery and were admitted to the intensive care unit perioperatively at the General Hospital Vienna. MEASUREMENTS AND MAIN RESULTS Among the 2,789 patients included in the analysis, 167 (6%) were readmitted to the intensive care unit during the same hospital stay. Preoperative risk factors associated with ICU readmission included end-stage renal failure (odds ratio [OR] 2.80, 95% CI: 1.126-6.964), arrhythmia (OR 1.59, 95% CI: 1.019-2.480), chronic obstructive pulmonary disease (OR 1.51, 95% CI: 1.018-2.237), age >80 (OR 2.55, 95% CI: 1.189-5.466), and European System for Cardiac Operative Risk Evaluation II >8 (OR 1.40, 95% CI: 1.013-1.940). Readmitted patients were more likely to die than nonreadmitted patients (OR 5.3, 95% CI: 3.284-8.558). In-hospital mortality in readmitted patients was 19.2%, whereas that in the nonreadmitted study population was 5.1%. CONCLUSION Preoperative risk assessment is crucial for identifying cardiac surgery patients at risk of ICU readmission and in-hospital death. The potentially modifiable risk factors pinpointed by this study call for the optimization of care before surgery and after ICU discharge.
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Affiliation(s)
- Caroline Holaubek
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Fabian Winter
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Anita Lesjak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Philipp Opfermann
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernhard Urbanek
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christine Schlömmer
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Mohamed Mouhieddine
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Andreas Zuckermann
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria.
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Lloyd-Donald P, Lee WS, Hooper JW, Lee DK, Moore A, Chandra N, McCall P, Seevanayagam S, Matalanis G, Warrillow S, Weinberg L. Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative. BMC Res Notes 2021; 14:201. [PMID: 34022969 PMCID: PMC8140586 DOI: 10.1186/s13104-021-05620-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/15/2021] [Indexed: 12/13/2022] Open
Abstract
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).
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Affiliation(s)
| | - Wen-Shen Lee
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - James W Hooper
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University School of Medicine, Seoul, Korea
| | - Alice Moore
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | - Nikhil Chandra
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
| | - Peter McCall
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Health, Melbourne, Australia
| | - Stephen Warrillow
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Melbourne, VIC, Australia. .,Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Australia.
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Naganuma M, Tokita T, Sato Y, Kasai T, Kudo Y, Suzuki N, Masuda S, Nagaya K. Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study. J Cardiothorac Vasc Anesth 2021; 36:477-482. [PMID: 34099376 DOI: 10.1053/j.jvca.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN A propensity score-matched retrospective study. SETTING A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.
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Affiliation(s)
- Masaaki Naganuma
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yuri Sato
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Toshinori Kasai
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yasushi Kudo
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobuaki Suzuki
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Shinya Masuda
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Koichi Nagaya
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
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13
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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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15
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Sung TY, Lee DK, Bang J, Choi J, Shin S, Kim TY. Remifentanil-based propofol-supplemented vs. balanced sevoflurane-sufentanil anesthesia regimens on bispectral index recovery after cardiac surgery: a randomized controlled study. Anesth Pain Med (Seoul) 2020; 15:424-433. [PMID: 33329845 PMCID: PMC7724124 DOI: 10.17085/apm.20022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/01/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background The present study was to compare the potential impact of remifentanil-based propofol-supplemented anesthesia regimen vs. conventional sevoflurane-sufentanil balanced anesthesia on postoperative recovery of consciousness indicated by bispectral index (BIS) values in patients undergoing cardiac surgery. Methods Patients undergoing cardiac surgery were randomly allocated to get the remifentanil-based propofol-supplemented anesthesia employing target-controlled infusion (TCI) of remifentanil and propofol (Group-PR, n = 15) or a balanced-anesthesia employing sevoflurane-inhalation and TCI-sufentanil (Group-C, n = 19). In Group-PR, plasma concentration (Cp) of TCI-remifentanil was fixed at 20 ng/ml, and the effect-site concentration of TCI-propofol was adjusted within 0.8–2.0 μg/ml to maintain BIS value of 40–60. In Group-C, sevoflurane dosage was adjusted within 1–1.5 minimum alveolar concentration to maintain BIS of 40–60, and Cp of TCI-sufentanil was fixed at 0.4 ng/ml. The inter-group difference in the time for achieving postoperative BIS > 80 (T-BIS80) in the intensive care unit was determined as the primary outcome. The inter-group difference in the extubation time was determined as the secondary outcome. Results T-BIS80, was shorter in Group-PR than Group-C (121.4 ± 64.9 min vs. 182.9 ± 85.1 min, respectively; the difference of means –61.5 min; 95% CI –115.7 to –7.4 min; effect size 0.812; P = 0.027). The extubation time was shorter in Group-PR than in Group-C (434.7 ± 131.3 min vs. 946.6 ± 393.3 min, respectively, P < 0.001). Conclusions Compared with the conventional sevoflurane-sufentanil balanced anesthesia, the remifentanil-based propofol-supplemented anesthesia showed significantly faster postoperative conscious recovery in patients undergoing cardiac surgery.
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Affiliation(s)
- Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Korea
| | - Dong-Kyu Lee
- Department of Anesthesiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jiyon Bang
- epartment of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jimin Choi
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Saemi Shin
- College of Life Science and Biotechnology, Korea University, Seoul, Korea
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Khidr AM, Khalil MA, Abdulfattah D, El Tahan MR. A Comparison of Different Remifentanil Effect-Site Concentrations to Allow for Early Extubation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:470-481. [PMID: 32389453 DOI: 10.1053/j.jvca.2020.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Assess different remifentanil effect-site concentrations (Ce) for readiness for extubation time after cardiac surgery. DESIGN Prospective, randomized, blinded, controlled study. DESIGN Single university hospital. PARTICIPANTS Seventy-three patients scheduled for cardiac surgery. INTERVENTIONS After ethical approval, patients scheduled for cardiac surgery with target-controlled propofol infusion were randomly assigned to receive remifentanil effect-site concentrations (Ce) of 1, 2, or 3 ng/mL (n = 25, 25, and 23, respectively). MEASUREMENTS AND MAIN RESULTS The primary endpoint was readiness for extubation. Secondary outcomes were also recorded, including the cumulative doses and number of changes of propofol and remifentanil, hemodynamic variables, time to spontaneous eye opening and breathing, actual extubation, incidences of light anesthesia and myocardial ischemia, need for vasopressors and inotropes, and intensive care unit (ICU) and hospital stays. There was no difference in the time to readiness for extubation in any of the groups (0.1 ng/mL: 11.5 min (5-37); 0.2 ng/mL: 22 min (10-35); and 0.3 ng/mL: 21 min (10-49), p < 0.532); however, there was a significant difference among the 3 groups regarding the cumulative remifentanil doses (p < 0.001). Time to spontaneous eye opening and breathing, actual extubation, use of vasopressors and inotropes, incidences of light anesthesia and myocardial ischemia, and length of ICU and hospital stay were similar for all groups. Forty-six of the 73 patients were extubated on-table. CONCLUSION Remifentanil Ce 1, 2, and 3 ng/mL produced comparative effects on time to extubation and hemodynamic responses to cardiac surgery. The 3 Ce resulted in immediate on-table extubation in 50% of patients.
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Affiliation(s)
- Alaa M Khidr
- King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Mohamed A Khalil
- King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia; Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dalia Abdulfattah
- Clinical Nursing Supervisor Operating Room, Day Surgery, CSSD, Hemodialysis, and PDU, King Fahd Hospital of the Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Mohamed R El Tahan
- King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia.
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Bhavsar R, Ryhammer PK, Greisen J, Jakobsen CJ. Fast-track cardiac anaesthesia protocols: Is quality pushed to the edge? Ann Card Anaesth 2020; 23:142-148. [PMID: 32275026 PMCID: PMC7336968 DOI: 10.4103/aca.aca_204_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The quest for methods expediting rapid postoperative patient turnover has triggered implementation of various fast-track cardiac anaesthesia protocols. Using three different fast-track protocols in randomized controlled studies (RCT) conducted 2010-2016 we found minimal achievements in ventilation time together with actual and eligible length of stay in cardiac recovery unit. The comparable control group patients were evaluated in this retrospective post hoc analysis, for an association between above mentioned parameters and quality parameters, to assess whether the marginal gains have been at the expense of quality of recovery and patient comfort. Method 90 control patients from three RCT with comparable demographic parameters and receiving standard department treatment were evaluated using time parameters and an objective/semi-objective Intensive Care Unit (ICU) score system (IDS score). Results Ventilation time was statistical significant lower in latest study (C) than the early (A) and intermedium (B) studies (A=293, B=261, C=205 minutes; P=0.04). The IDS was lower at extubation and all time points in the early study compared to other studies (P < 0.001;). The average IDS in latest study were the double of previous studies at the end of observations, and marginally above the acceptable score for discharge. The postoperative morphine requirement A=15.0, B=10.0 and C=26.5 mg; P=0.002) was statistical significant higher in the latest study compared to previous studies. Conclusion The implementation of strict fast-track protocols resulting in shorter ventilation time did not convert to earlier eligibility to discharge from the ICU. However, the quality of recovery appears challenged.
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Affiliation(s)
- Rajesh Bhavsar
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pia K Ryhammer
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Jacob Greisen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Carl-Johan Jakobsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark
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Xu J, Zhou G, Li Y, Li N. Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery. BMC Pediatr 2019; 19:487. [PMID: 31829170 PMCID: PMC6907131 DOI: 10.1186/s12887-019-1832-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the outcomes of ultra-fast-track anesthesia (UFTA) and conventional anesthesia in cardiac surgery for children with congenital heart disease (CHD) and low birth weight. METHODS One hundred and ninety-four CHD children, aged 6 months to 2 years, weighting 5 to 10 kg, were selected for this study. The 94 boys and 100 girls with the American Society of Anesthesiologists (ASA) physical status III and IV were randomly divided into two groups each consisting of 97 patients, and were subjected to ultra-fast-track and conventional anesthesia for cardiac surgery. For children in UFTA group, sevoflurane was stopped when cardiopulmonary bypass (CPB) started and cis-atracurium was stopped at the beginning of rewarming, and remifentanil (0.3 μg/kg/mim) was then infused. Propofol and remifentanil were discontinued at skin closure. 10 min after surgery, extubation was performed in operating room. For children in conventional anesthesia group, anesthesia was given routinely and they were directly sent to ICU with a tracheal tube. Extubation time, ICU stay and hospital stay after operation were recorded. Sedation-agitation scores (SAS) were assessed and adverse reactions as well as other anesthesia -related events were recorded. RESULTS The extubation time, ICU stay and hospital stay were significantly shorter in UFTA group (P < 0.05) and SAS at extubation was lower in UFTA group than in conventional anesthesia group, but similar in other time points. For both groups, no airway obstruction and other serious complications occurred, and incidence of other anesthesia -related events were low. CONCLUSIONS UFTA shortens extubation time, ICU stay and hospital stay for children with CHD and does not increase SAS and incidence of adverse reactions.
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Affiliation(s)
- Jing Xu
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Guanghua Zhou
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China
| | - Yanpei Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
| | - Na Li
- Department of Anesthesiology, China Emergency General Hospital, 29 Liufangnanli Rd, Beijing, 100028, China.
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Wang ZC, Chen Q, Cao H, Zhang GC, Chen LW, Yu LL, Luo ZR. Fast-Track Cardiac Anesthesia for Transthoracic Device Closure of Perimembranous Ventricular Septal Defects in Children: A Single Chinese Cardiac Center Experience. J Cardiothorac Vasc Anesth 2019; 33:1262-1266. [DOI: 10.1053/j.jvca.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Indexed: 11/11/2022]
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Howes C. A Case Report Examining Early Extubation Following Congenital Heart Surgery in a Low Resource Setting. Front Pediatr 2019; 6:311. [PMID: 30941332 PMCID: PMC6433832 DOI: 10.3389/fped.2018.00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
This case report aims to critically analyse the evidence surrounding early extubation in the post-operative phase following complex congenital cardiac surgery. Child A was an 8 year old female who had undergone complex congenital cardiac surgery during an international surgical charity mission. On admission to the paediatric intensive care unit Child A appeared to be in good condition and no major complications had occurred intra-operatively. This was considered alongside the situational pressures of resource limitations and the mission's aim to offer surgery to as many children as possible during the available time frame. The decision was made by the team that Child A was a suitable candidate for 'early extubation.' Some members of the team were uncomfortable with this approach and felt it could lead to poorer outcomes for patients. Current evidence surrounding early extubation both within international surgical mission trips to low-income and middle-income countries and established cardiac centres within high-income countries is examined and discussed alongside the context of resource limitation. Although the process and implications of early extubation following cardiac surgery needs further research, on the basis of the evidence currently available clinicians could potentially encourage the use of early extubation within clinical practice (for appropriately selected patients) through the utilisation of a multidisciplinary approach, both within the UK and during international surgical charity missions to low-income and middle-income countries.
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Affiliation(s)
- Catherine Howes
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
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Yu LS, Chen Q, Wang ZC, Cao H, Chen LW, Zhang GC. Comparison of Fast-Track and Conventional Anesthesia for Transthoracic Closure of Ventricular Septal Defects in Pediatric Patients. Ann Thorac Cardiovasc Surg 2019; 25:205-210. [PMID: 30867385 PMCID: PMC6698717 DOI: 10.5761/atcs.oa.18-00242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To compare and analyze the safety and efficacy of fast-track and conventional anesthesia for transthoracic closure of ventricular septal defects (VSDs) in pediatric patients. METHODS A total of 82 pediatric patients undergoing transthoracic closure of VSDs between September and December 2017 were retrospectively analyzed. The patients were divided into two groups, including 42 patients in group F (fast-track anesthesia) and 40 patients in group C (conventional anesthesia). The perioperative clinical data of both groups were collected and statistically analyzed. RESULTS There were no fatal complications in both groups. No complete atrioventricular block (AVB), new aortic valve regurgitation, and device closure failure were observed. No significant difference was found in preoperative general data or intraoperative hemodynamic changes between the two groups (P >0.05). However, the mechanical ventilation time, length of postoperative intensive care unit (ICU) stay, length of hospital stay, and hospitalization expenses of group F were significantly lower than those of group C (P <0.05). CONCLUSION It is safe and effective to use fast-track anesthesia for transthoracic closure of VSDs in pediatric patients.
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Affiliation(s)
- Ling-Shan Yu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Zeng-Chun Wang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Gui-Can Zhang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Huang Q, Lin LY, Lin XZ. Comparison of Remifentanil-Based Fast-Track and Fentanyl-Based Routine Cardiac Anesthesia for Intraoperative Device Closure of Atrial Septal Defect (ASD) in Pediatric Patients. Med Sci Monit 2019; 25:1187-1193. [PMID: 30759074 PMCID: PMC6381809 DOI: 10.12659/msm.913387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background The aim of this study was to evaluate the effectiveness and safety of remifentanil-based fast-track anesthesia for intraoperative device closure of atrial septal defects (ASDs). Material/Methods The clinical data of 152 pediatric patients who received intraoperative device closure of ASD in our hospital from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into 2 groups: group F (remifentanil-based fast-track anesthesia group, n=72) and group C (fentanyl-based routine anesthesia group, n=80). The relevant data from 2 groups were collected and analyzed. Results No significant differences were found in the preoperative data or intraoperative hemodynamic index between these 2 groups. Group C was significantly inferior to group F regarding the duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, and hospitalization expenses (P<0.05). In terms of postoperative complications, no death, third-degree atrioventricular block, occluder detachment, or residual leakage was reported in either group. The incidence of lung infections and bronchospasm was significantly higher in group C than in group F. There were no anesthetic-related complications. Conclusions The application of remifentanil-based fast-track anesthesia for intraoperative device closure of ASD is as effective and safe as fentanyl-based routine anesthesia. Moreover, remifentanil-based fast-track anesthesia has the advantages of shorter duration of mechanical ventilation, shorter length of hospital and ICU stay, fewer postoperative complications, and lower hospitalization expenses, and is therefore worthy of promotion in clinical practice.
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Affiliation(s)
- Qing Huang
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Lan-Ying Lin
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
| | - Xian-Zhong Lin
- Department of Anesthesia, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China (mainland)
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Zakhary WZA, Turton EW, Flo Forner A, von Aspern K, Borger MA, Ender JK. A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients. Anaesthesia 2019; 74:602-608. [PMID: 30663045 PMCID: PMC6590640 DOI: 10.1111/anae.14572] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2018] [Indexed: 11/30/2022]
Abstract
We retrospectively compared patients receiving remifentanil with patients receiving sufentanil undergoing fast-track cardiac surgery. After 1:1 propensity score matching there were 609 patients in each group. The sufentanil group had a significantly longer mean (SD) ventilation time compared with the remifentanil group; 122 (59) vs. 80 (44) min, p < 0.001 and longer mean (SD) length of stay in the recovery area; 277 (77) vs. 263 (78) min, p = 0.002. The sufentanil group had a lower mean (SD) visual analogue pain score than the remifentanil group; 1.5 (1.2) vs. 2.4 (1.5), p < 0.001 and consumed less mean (SD) piritramide (an opioid analgesic used in our hospital); 2.6 (4.7) vs. 18.9 (7.3) mg, p < 0.001. The results of our study show that although remifentanil was more effective in reducing time to tracheal extubation and length of stay in the recovery area, there was an increased requirement for postoperative analgesia when remifentanil was used.
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Affiliation(s)
- W Z A Zakhary
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - E W Turton
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - A Flo Forner
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
| | - K von Aspern
- University Department for Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - M A Borger
- University Department for Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - J K Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig, Germany
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Totonchi Z, Azarfarin R, Jafari L, Alizadeh Ghavidel A, Baharestani B, Alizadehasl A, Mohammadi Alasti F, Ghaffarinejad MH. Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial. Anesth Pain Med 2018; 8:e80158. [PMID: 30533392 PMCID: PMC6240920 DOI: 10.5812/aapm.80158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/08/2018] [Accepted: 09/13/2018] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Louise Jafari
- Anesthesiologist, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh Ghavidel
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahador Baharestani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Brandão PGM, Lobo FR, Ramin SL, Sakr Y, Machado MN, Lobo SM. Dexmedetomidine as an Anesthetic Adjuvant in Cardiac Surgery: a Cohort Study. Braz J Cardiovasc Surg 2017; 31:213-218. [PMID: 27737403 PMCID: PMC5062707 DOI: 10.5935/1678-9741.20160043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 06/08/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: α-2-agonists cause sympathetic inhibition combined with
parasympathetic activation and have other properties that could be
beneficial during cardiac anesthesia. We evaluated the effects of
dexmedetomidine as an anesthetic adjuvant compared to a control group during
cardiac surgery. METHODS: We performed a retrospective analysis of prospectively collected data from
all adult patients (> 18 years old) undergoing cardiac surgery. Patients
were divided into two groups, regarding the use of dexmedetomidine as an
adjuvant intraoperatively (DEX group) and a control group who did not
receive α-2-agonist (CON group). RESULTS: A total of 1302 patients who underwent cardiac surgery, either coronary
artery bypass graft or valve surgery, were included; 796 in the DEX group
and 506 in the CON group. Need for reoperation (2% vs.
2.8%, P=0.001), type 1 neurological injury (2%
vs. 4.7%, P=0.005) and prolonged
hospitalization (3.1% vs. 7.3%, P=0.001)
were significantly less frequent in the DEX group than in the CON group.
Thirty-day mortality rates were 3.4% in the DEX group and 9.7% in the CON
group (P<0.001). Using multivariable Cox regression
analysis with in hospital death as the dependent variable, dexmedetomidine
was independently associated with a lower risk of 30-day mortality (odds
ratio [OR]=0.39, 95% confidence interval [CI]: 0.24-0.65,
P≤0.001). The Logistic EuroSCORE (OR=1.05, 95% CI:
1.02-1.10, P=0.004) and age (OR=1.03, 95% CI: 1.01-1.06,
P=0.003) were independently associated with a higher
risk of 30-day mortality. CONCLUSION: Dexmedetomidine used as an anesthetic adjuvant was associated with better
outcomes in patients undergoing coronary artery bypass graft and valve
surgery. Randomized prospective controlled trials are warranted to confirm
our results.
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Affiliation(s)
- Paulo Gabriel Melo Brandão
- Division of Critical Care Medicine, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Francisco Ricardo Lobo
- Division of Anesthesiology, Department of Surgery, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Serginando Laudenir Ramin
- Division of Anesthesiology, Department of Surgery, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University, Jena, Germany
| | - Mauricio Nassau Machado
- Division of Cardiology. Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | - Suzana Margareth Lobo
- Division of Critical Care Medicine, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
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Zayat R, Menon AK, Goetzenich A, Schaelte G, Autschbach R, Stoppe C, Simon TP, Tewarie L, Moza A. Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience. J Cardiothorac Surg 2017; 12:10. [PMID: 28179009 PMCID: PMC5299681 DOI: 10.1186/s13019-017-0573-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/25/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications. METHODS From March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVAD ultra ) in 13 patients. After propensity score matching, we compared the LVAD ultra group with a matched group (LVAD match ) receiving conventional anesthesia management. RESULTS Patients in the LVAD ultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival. CONCLUSION In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.
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Affiliation(s)
- Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
| | - Ares K Menon
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Andreas Goetzenich
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Gereon Schaelte
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ruediger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Christian Stoppe
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ajay Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
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Zakhary WZA, Turton EW, Ender JK. Post-operative patient care and hospital implications of fast track. Eur Heart J Suppl 2017. [DOI: 10.1093/eurheartj/suw055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Heijmans JH, Lancé MD. Fast track minimally invasive aortic valve surgery: patient selection and optimizing. Eur Heart J Suppl 2017. [DOI: 10.1093/eurheartj/suw056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Putzu A, Capelli B, Belletti A, Cassina T, Ferrari E, Gallo M, Casso G, Landoni G. Perioperative statin therapy in cardiac surgery: a meta-analysis of randomized controlled trials. Crit Care 2016; 20:395. [PMID: 27919293 PMCID: PMC5139027 DOI: 10.1186/s13054-016-1560-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/07/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Several studies suggest beneficial effects of perioperative statin therapy on postoperative outcome after cardiac surgery. However, recent randomized controlled trials (RCTs) show potential detrimental effects. The objective of this systematic review is to examine the association between perioperative statin therapy and clinical outcomes in cardiac surgery patients. METHODS Electronic databases were searched up to 1 November 2016 for RCTs of preoperative statin therapy versus placebo or no treatment in adult cardiac surgery. Postoperative outcomes were acute kidney injury, atrial fibrillation, myocardial infarction, stroke, infections, and mortality. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using fixed-effects meta-analyses. Primary analysis was restricted to trials with low risk of bias according to Cochrane methodology, and sensitivity analyses examined whether the risk of bias of included studies was associated with different results. We performed trial sequential analysis (TSA) to test the strength of the results. RESULTS We included data from 23 RCTs involving 5102 patients. Meta-analysis of trials with low risk of bias showed that statin therapy was associated with an increase in acute kidney injury (314 of 1318 (23.82%) with statins versus 262 of 1319 (19.86%) with placebo; OR 1.26 (95%CI 1.05 to 1.52); p = 0.01); these results were supported by TSA. No difference in postoperative atrial fibrillation, myocardial infarction, stroke, infections, or mortality was present. On sensitivity analysis, statin therapy was associated with a slight increase in hospital mortality. Meta-analysis including also trials with high or unclear risk of bias showed no beneficial effects of statin therapy on any postoperative outcomes. CONCLUSIONS There is no evidence that statin therapy in the days prior to cardiac surgery is beneficial for patients' outcomes. Particularly, statins are not protective against postoperative atrial fibrillation, myocardial infarction, stroke, or infections. Statins are associated with a possible increased risk of acute kidney injury and a detrimental effect on hospital survival could not be excluded. Future RCTs should further evaluate the safety profile of this therapy in relation to patients' outcomes and assess the more appropriate time point for discontinuation of statins before cardiac surgery.
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Affiliation(s)
- Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Bruno Capelli
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milano, Italy
| | - Tiziano Cassina
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Enrico Ferrari
- Department of Cardiac Surgery, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Michele Gallo
- Department of Cardiac Surgery, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Gabriele Casso
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, Lugano, Switzerland
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milano, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, Milano, Italy
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Jansen Klomp WW, Brandon Bravo Bruinsma GJ, Peelen LM, Nierich AP, Grandjean JG, van 't Hof AWJ. Clinical recognition of acute aortic dissections: insights from a large single-centre cohort study. Neth Heart J 2016; 25:200-206. [PMID: 27882524 PMCID: PMC5313444 DOI: 10.1007/s12471-016-0921-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aims Acute aortic dissection (AD) requires immediate treatment, but is a diagnostic challenge. We studied how often AD was missed initially, which patients were more likely to be missed and how this influenced patient management and outcomes. Methods A retrospective cohort study including 200 consecutive patients with AD as the final diagnosis, admitted to a tertiary hospital between 1998 and 2008. The first differential diagnosis was identified and patients with and without AD included were compared. Characteristics associated with a lower level of suspicion were identified using multivariable logistic regression, and Cox regression was used for survival analyses. Missing data were imputed. Results Mean age was 63 years, 39% were female and 76% had Stanford type A dissection. In 69% of patients, AD was included in the first differential diagnosis; this was less likely in women (adjusted relative risk [aRR]: 0.66, 95% CI: 0.44–0.99), in the absence of back pain (aRR: 0.51, 95% CI: 0.30–0.84), and in patients with extracardiac atherosclerosis (aRR: 0.64, 95% CI: 0.43–0.96). Absence of AD in the differential diagnosis was associated with the use of more imaging tests (1.8 vs. 2.3, p = 0.01) and increased time from admission to surgery (1.8 vs. 10.1 h, p < 0.01), but not with a difference in the adjusted long-term all-cause mortality (hazard ratio: 0.76, 95% CI: 0.46–1.27). Conclusion Acute aortic dissection was initially not suspected in almost one-third of patients, this was more likely in women, in the absence of back pain and in patients with extracardiac atherosclerosis. Although the number of imaging tests was higher and time to surgery longer, patient outcomes were similar in both groups. Electronic supplementary material The online version of this article (doi:10.1007/s12471-016-0921-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- W W Jansen Klomp
- Department of Cardiology, Isala, Zwolle, The Netherlands.
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - L M Peelen
- Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Anaesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A P Nierich
- Department of (Thoracic) Anaesthesia and Intensive Care, Isala, Zwolle, The Netherlands
| | - J G Grandjean
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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Bhavsar R, Ryhammer PK, Greisen J, Rasmussen LA, Jakobsen CJ. Remifentanil Compared With Sufentanil Does Not Enhance Fast-Track Possibilities in Cardiac Surgery—A Randomized Study. J Cardiothorac Vasc Anesth 2016; 30:1212-20. [DOI: 10.1053/j.jvca.2015.12.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Indexed: 11/11/2022]
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Abstract
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.
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Affiliation(s)
- Wai‐Tat Wong
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Veronica KW Lai
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
| | - Yee Eot Chee
- Queen Mary HospitalDepartment of AnaesthesiologyPokfulamHong Kong
| | - Anna Lee
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
- The Chinese University of Hong KongHong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of MedicineShatinNew TerritoriesHong Kong
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Schraag S. Postoperative management. Best Pract Res Clin Anaesthesiol 2016; 30:381-93. [PMID: 27650347 DOI: 10.1016/j.bpa.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023]
Abstract
Most patients undergoing major aortic surgery have multiple comorbidities and are at high risk of postoperative complications that affect multiple organ systems. Different aortic pathologies and surgical repair techniques have specific impact on the postoperative course. Ischemia-reperfusion injury is the common denominator in aortic surgery and influences the integrity of end-organ function. Common postoperative problems include hemodynamic instability due to the immediate inflammatory response, renal impairment, spinal cord ischemia, respiratory failure with prolonged mechanical ventilation, and gastrointestinal symptoms such as ileus or mesenteric ischemia. Focused care bundles to establish homeostasis and a team working toward an early functional recovery determine the success of effective rehabilitation and outcomes after aortic surgery.
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Affiliation(s)
- Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, Scotland, United Kingdom.
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Schraag S. The Current Role of Total Intravenous Anesthesia in Cardiac Surgery: Total Intravenous Anesthesia and Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29 Suppl 1:S27-30. [DOI: 10.1053/j.jvca.2015.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/11/2022]
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Grawe E, Wojciechowski PJ, Hurford WE. Balancing early extubation and rates of reintubation in cardiac surgical patients: where does the fulcrum lie? J Cardiothorac Vasc Anesth 2015; 29:549-50. [PMID: 26009284 DOI: 10.1053/j.jvca.2015.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Erin Grawe
- Department of Anesthesiology, University of Cincinnati Cincinnati, OH
| | | | - William E Hurford
- Department of Anesthesiology, University of Cincinnati Cincinnati, OH
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Abstract
Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.
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Affiliation(s)
- Meghan Prin
- 1 Department of Anesthesiology, Columbia University, New York, New York
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Akhtar MI, Hamid M, Minai F, Wali AR, Anwar-Ul-Haq, Aman-Ullah M, Ahsan K. Safety profile of fast-track extubation in pediatric congenital heart disease surgery patients in a tertiary care hospital of a developing country: An observational prospective study. J Anaesthesiol Clin Pharmacol 2014; 30:355-9. [PMID: 25190943 PMCID: PMC4152675 DOI: 10.4103/0970-9185.137267] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background and Aims: Early extubation after cardiac operations is an important aspect of fast-track cardiac anesthesia. In order to reduce or eliminate the adverse effects of prolonged ventilation in pediatric congenital heart disease (CHD) surgical patients, the concept of early extubation has been analyzed at our tertiary care hospital. The current study was carried out to record the data to validate the importance and safety of fast-track extubation (FTE) with evidence. Materials and Methods: A total of 71 patients, including male and female aged 6 months to 18 years belonging to risk adjustment for congenital heart surgery-1 category 1, 2, and 3 were included in this study. All patients were anesthetized with a standardized technique and surgery performed by the same surgeon. At the end of operation, the included patients were assessed for FTE and standard extubation criteria were used for decision making. Results: Of the total 71 patients included in the study, 26 patients (36.62%) were extubated in the operating room, 29 (40.85%) were extubated within 6 h of arrival in cardiovascular intensive care unit and 16 (22.54%) were unable to get extubated within 6 h due to multiple reasons. Hence, overall success rate was 77.47%. The reasons for delayed extubation were significant bleeding in 5 (31.3%) cases, hemodynamic instability (low cardiac output syndrome) in 4 (25%) cases, respiratory complication in 2 (12.5%), bleeding plus hemodynamic instability in 2 (12.5) cases, hemodynamic instability, and respiratory complication in 2 (12.5%) cases and triad of hemodynamic instability, bleeding and respiratory complication in 1 (6.5%) case. There was no reintubation in the FTE cases. Conclusion: On the basis of the current study results, it is recommended to use FTE in pediatric CHD surgical patients safely with multidisciplinary approach.
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Affiliation(s)
| | - Mohammad Hamid
- Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
| | - Fauzia Minai
- Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
| | - Amina Rehmat Wali
- Department of Nursing Services, Aga Khan University Hospital, Karachi, Pakistan
| | - Anwar-Ul-Haq
- Department of Pediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Muneer Aman-Ullah
- Department of Cardiac Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Khalid Ahsan
- Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
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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: 55] [Impact Index Per Article: 5.5] [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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Thoma BN, Li J, McDaniel CM, Wordell CJ, Cavarocchi N, Pizzi LT. Clinical and economic impact of substituting dexmedetomidine for propofol due to a US drug shortage: examination of coronary artery bypass graft patients at an urban medical centre. PHARMACOECONOMICS 2014; 32:149-157. [PMID: 24254138 DOI: 10.1007/s40273-013-0116-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Propofol has reduced healthcare costs in coronary artery bypass graft (CABG) surgery patients by decreasing post-operative duration of mechanical ventilation. However, the US shortage of propofol necessitated the use of alternative agents. OBJECTIVE This study sought to evaluate clinical and economic implications of substituting dexmedetomidine for propofol in patients undergoing CABG surgery. METHODS This was a retrospective cohort study. Patients undergoing isolated, elective CABG surgery and sedated with either propofol or dexmedetomidine during the study period were included. The cohorts were matched 1:1 based on important characteristics. The primary outcome was the number of patients achieving a post-operative duration of mechanical ventilation ≤6 h. Secondary outcomes were post-operative intensive care unit (ICU) length of stay (LOS) ≤48 h, total post-operative LOS ≤5 days, the need for adjunctive opioid therapy and associated cost savings. Variables recorded included patient demographics, co-morbid medical conditions, health risks, sedation drug doses, post-operative medical complications and sedation-related adverse events. Univariate and multivariate analyses were completed to examine the relationship between these covariates and post-operative LOS. The cost analysis consisted of examination of the net financial benefit (or cost) of choosing dexmedetomidine versus propofol in the study population, with utilisation observed in the study converted to costs using institutional data from the Premier database. RESULTS Eighty-four patients were included, with 42 patients per cohort. Mechanical ventilation duration ≤6 h was achieved in 24 (57.1 %) versus 7 (16.7 %) in the dexmedetomidine and propofol cohorts, respectively (p < 0.001). More patients treated with dexmedetomidine achieved ICU LOS ≤48 h (p < 0.05) and total hospital LOS ≤5 days (p < 0.05), as compared with the propofol group. Multivariate analysis revealed that having one or more post-operative medical complication was the most significant predictor of increased post-operative LOS, whereas choosing dexmedetomidine was also significant in terms of reduced post-operative LOS. The estimated net financial benefit of choosing dexmedetomidine versus propofol was US$2,613 per patient (year 2012 value). CONCLUSIONS Findings suggest that use of dexmedetomidine as an alternative to propofol for sedation of CABG patients post-operatively contributes to reduced mechanical ventilation time, ICU LOS and post-operative LOS. Higher drug costs resulting from the propofol shortage were offset by savings in post-operative room and board costs. Additional savings may be possible by preventing medical complications to the extent possible.
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Affiliation(s)
- Brandi N Thoma
- Thomas Jefferson University Hospital, 111 South 11th Street, Suite 2260, Philadelphia, PA, 19107, USA,
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Khanykin B, Siddiqi R, Jensen PF, Bigler DR, Atroshchenko GV. Comparison of Remifentanil and Low-Dose Fentanyl for Fast-Track Cardiac Anesthesia: A Prospective Randomized Study. Heart Surg Forum 2013; 16:E324-8. [DOI: 10.1532/hsf98.2013229] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Background:</b> Different anesthetic techniques have been used for fast tracking in cardiac anesthesia. Remifentanil, with its unique pharmacokinetic profile, could be an ideal drug for fast tracking. Possible limitations of remifentanil are rapid onset of postoperative pain after discontinuation of the drug infusion, which may increase the risk of an ischemic event. We conducted this randomized study to compare the efficacy of remifentanil versus low doses of fentanyl in fast-track cardiac anesthesia. It has been hypothesized that remifentanil would provide a safe anesthesia with no impact on myocardial function and with positive effects on extubation time and mobilization.</p><p><b>Methods:</b> We compared the postoperative course of patients, the remifentanil group (RG) and the low-dose fentanyl group (LDFG), in whom remifentanil and low-dose fentanyl, respectively, were used for fast-track cardiac anesthesia. The study was designed as a prospective randomized study. The primary outcomes were changes in the cardiac index and creatine kinase MB fraction (CKMB), extubation times, mobilization times, and lengths of stay in the intensive care unit (ICU) and the hospital. Frequency of myocardial infarction (MI), reoperations due to excessive bleeding, renal impairment, and cerebral complications were registered as well.</p><p><b>Results:</b> Seventy-one patients were enrolled in the study, and 7 were excluded due to difficult airway, bleeding, and technical difficulties. The RG comprised 33 patients and the LDFG comprised of 31 patients. There were no differences between the groups in terms of age, Euroscore, types of surgery, extracorporeal circulation, and aortic cross-clamp time. We did not find significant difference in cardiac index, CKMB, extubation times, mobilization times, length of stay in the ICU and in the hospital between the groups. Postoperative complications such as MI, rates of reoperations, renal and cerebral complications and incidence of atrial fibrillation did not show any significant differences.</p><p><b>Conclusions:</b> Remifentanil fast-track anesthesia for cardiac patients has no negative impact on myocardial function. Both remifentanil and low-dose fentanyl are equally effective and safe for fast-track cardiac anesthesia. The study did not highlight any statistical superiority of remifentanil anesthesia over low-dose fentanyl anesthesia.</p>
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Anastasiadis K, Asteriou C, Antonitsis P, Argiriadou H, Grosomanidis V, Kyparissa M, Deliopoulos A, Konstantinou D, Tossios P. Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study. J Cardiothorac Vasc Anesth 2013; 27:859-64. [DOI: 10.1053/j.jvca.2013.01.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 11/11/2022]
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Bilecen S, de Groot JA, Kalkman CJ, Spanjersberg AJ, Moons KG, Nierich AP. Effectiveness of a cardiac surgery-specific transfusion protocol. Transfusion 2013; 54:708-16. [DOI: 10.1111/trf.12346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 05/29/2013] [Accepted: 05/30/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Süleyman Bilecen
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Joris A.H. de Groot
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Cor J. Kalkman
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Alexander J. Spanjersberg
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Karel G.M. Moons
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Arno P. Nierich
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
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Effect of cardiopulmonary bypass on regional antibiotic penetration into lung tissue. Antimicrob Agents Chemother 2013; 57:2996-3002. [PMID: 23587954 DOI: 10.1128/aac.02627-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The use of cardiopulmonary bypass (CPB) during cardiac surgery causes regional ventilation-perfusion mismatch, contributing to regional disturbances in antibiotic penetration into lung tissue. Ventilation-perfusion mismatch is associated with postoperative pneumonia, a frequent and devastating complication after cardiac surgery. In this prospective clinical animal study, we performed in vivo microdialysis to determine the effect of CPB on regional penetration of levofloxacin (LVX) into lung tissue. Six pigs underwent surgery with CPB (CPB group), and another six pigs underwent surgery without CPB (off-pump coronary artery bypass grafting; OPCAB group). LVX (750 mg) was administered intravenously to all pigs immediately after surgery. For regional measurements of LVX in pulmonary concentrations, microdialysis probes were inserted in both lungs of each pig. Pigs were placed in the right lateral position. Time versus concentration profiles of unbound LVX were measured in the upper and lower lung tissue and plasma in all pigs. In all pigs, maximum concentrations (Cmax) of LVX were significantly lower in the upper lung than in the lower lung (OPCAB, P = 0.035; CPB, P < 0.001). Median Cmax of LVX showed a significant difference in the upper versus lower lung in the CPB group (P < 0.05). No significant difference was found in the median Cmax of LVX in the upper and the lower lung in the OPCAB group (P = 0.32). Our data indicate that CPB affects perioperative regional antibiotic penetration into lung tissue. Common clinical antibiotic dosing schemes should be reevaluated in patients undergoing coronary artery bypass grafting with CPB.
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Bilecen S, Peelen LM, Kalkman CJ, Spanjersberg AJ, Moons KG, Nierich AP. Fibrinogen Concentrate Therapy in Complex Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:12-7. [DOI: 10.1053/j.jvca.2012.06.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Indexed: 11/11/2022]
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From accuracy to patient outcome and cost-effectiveness evaluations of diagnostic tests and biomarkers: an exemplary modelling study. BMC Med Res Methodol 2013; 13:12. [PMID: 23368927 PMCID: PMC3724486 DOI: 10.1186/1471-2288-13-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proper evaluation of new diagnostic tests is required to reduce overutilization and to limit potential negative health effects and costs related to testing. A decision analytic modelling approach may be worthwhile when a diagnostic randomized controlled trial is not feasible. We demonstrate this by assessing the cost-effectiveness of modified transesophageal echocardiography (TEE) compared with manual palpation for the detection of atherosclerosis in the ascending aorta. METHODS Based on a previous diagnostic accuracy study, actual Dutch reimbursement data, and evidence from literature we developed a Markov decision analytic model. Cost-effectiveness of modified TEE was assessed for a life time horizon and a health care perspective. Prevalence rates of atherosclerosis were age-dependent and low as well as high rates were applied. Probabilistic sensitivity analysis was applied. RESULTS The model synthesized all available evidence on the risk of stroke in cardiac surgery patients. The modified TEE strategy consistently resulted in more adapted surgical procedures and, hence, a lower risk of stroke and a slightly higher number of life-years. With 10% prevalence of atherosclerosis the incremental cost-effectiveness ratio was € 4,651 and € 481 per quality-adjusted life year in 55-year-old men and women, respectively. In all patients aged 65 years or older the modified TEE strategy was cost saving and resulted in additional health benefits. CONCLUSIONS Decision analytic modelling to assess the cost-effectiveness of a new diagnostic test based on characteristics, costs and effects of the test itself and of the subsequent treatment options is both feasible and valuable. Our case study on modified TEE suggests that it may reduce the risk of stroke in cardiac surgery patients older than 55 years at acceptable cost-effectiveness levels.
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Yu AL, Cai XZ, Gao XJ, Zhang ZW, Ma ZS, Ma LL, Wang LX. Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects. Med Princ Pract 2013; 22:234-8. [PMID: 23296121 PMCID: PMC5586751 DOI: 10.1159/000345844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 11/13/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study was designed to assess the factors that influence immediate extubation following totally thoracoscopic closure of congenital heart defects. SUBJECTS AND METHODS Clinical and operational data of 216 patients (87 males, average age 13.6 ± 10.9 years) were retrospectively analyzed. Atrial (ASD, n = 90) or ventricular septal defects (VSD, n = 126) were closed via a totally thoracoscopic approach. Ultra-fast-track anesthesia (UFTA) was used in all patients. RESULTS Immediate extubation in the operating room was successfully performed in 156 (72.2%) patients. A delayed extubation was completed in the intensive care unit in the remaining 60 (27.8%) patients. There was no significant difference in the age, sex, body weight, or type of congenital heart defect between the immediate and delayed extubation groups (p > 0.05). However, more patients in the delayed extubation group had severe preoperational pulmonary hypertension [8 (13.3%) vs. 4 (2.3%), p < 0.05]. The cardiopulmonary bypass time, aortic clamp time, and total duration of the surgery in the immediate extubation group were shorter than in the delayed extubation group (p < 0.05). Multivariate logistic regression analysis showed that preoperational pulmonary hypertension, duration of the surgery or cardiopulmonary bypass, and dosage of fentanyl used during the surgery were independent predictors for immediate extubation. CONCLUSIONS UFTA and immediate extubation in the operating room was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of ASD or VSD. Preoperational pulmonary hypertension, duration of the surgery, and the dosage of fentanyl used for UFTA were the determining factors for immediate extubation.
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Affiliation(s)
- Ai-Lan Yu
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Xing-Zhi Cai
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Xiu-Juan Gao
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Zong-Wang Zhang
- Department of Anesthesiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Zeng-Shan Ma
- Department of Cardiac Surgery, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
| | - Long-Le Ma
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
- Department of School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, N.S.W., Australia
| | - Le-Xin Wang
- Department of Cardiology, Liaocheng People's Hospital of Shandong University, Liaocheng, China, Australia
- Department of School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, N.S.W., Australia
- *Prof. Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2678, (Australia), E-Mail
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Abstract
BACKGROUND Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the 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 published in 2003. OBJECTIVES To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field. SELECTION CRITERIA 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 were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the 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 the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI). MAIN RESULTS Twenty-five trials involving 4118 patients were included in the review. There were two studies with a low risk of bias and nine studies with a high risk of bias. There were no differences in the risk of mortality within the first year after surgery between low-dose versus high-dose opioid based general anaesthesia groups (RR 0.58, 95% CI 0.28 to 1.18) and between early extubation protocol versus usual care groups (RR 0.84, 95% CI 0.40 to 1.75).There were no significant differences between low-dose versus high-dose opioid based anaesthesia groups for postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99), reintubation (RR 1.77, 95% CI 0.38 to 8.27), acute renal failure (RR 1.19, 95% CI 0.33 to 4.33), major bleeding (RR 0.48, 95% CI 0.16 to 1.44), and stroke (RR 1.17, 95% CI 0.36 to 3.78). Compared to the usual care, there were no significant differences in the risk of postoperative complications associated with early extubation: myocardial infarction (RR 0.94, 95% CI 0.55 to 1.60), reintubation (RR 1.91, 95% CI 0.90 to 4.07), acute renal failure (RR 0.77, 95% CI 0.19 to 3.10), major bleeding (RR 0.80, 95% CI 0.45 to 1.44), stroke (RR 0.87, 95% CI 0.31 to 2.46), major sepsis (RR 1.25, 95% CI 0.08 to 19.75) and wound infection (RR 0.67, 95% CI 0.25 to 1.83).Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital. One high quality cost-effectiveness analysis included in a randomized controlled trial showed that early extubation was likely to be cost-effective. AUTHORS' CONCLUSIONS The use of low-dose opioid based general anaesthesia and time-directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk. These fast-track interventions reduced the time to extubation and shortened the length of stay in the intensive care unit, but did not reduce the length of stay in the hospital.
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Affiliation(s)
- Fang Zhu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
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Weismann CG, Yang SF, Bodian C, Hollinger I, Nguyen K, Mittnacht AJ. Early Extubation in Adults Undergoing Surgery for Congenital Heart Disease. J Cardiothorac Vasc Anesth 2012; 26:773-6. [DOI: 10.1053/j.jvca.2012.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Indexed: 11/11/2022]
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Abstract
Ultra-fast-track anesthesia for cardiac surgery introduces risks to the patient that may be mitigated by transferring the patient to the intensive care unit with a secure airway. These risks include poorly controlled pain leading to catecholamine surges that result in arrhythmias, strain on fresh suture lines, and potentially myocardial ischemia. On the converse side, the patients frequently require titration of potent narcotic pain medicine that can lead to hypoxemia and hypercarbia in the immediate postoperative stage causing myocardial dysfunction. Finally, the economic benefit of ultra-fast-track anesthesia is questionable and until there is a complete cost analysis that includes operating room time, cost of ultra-fast-track medications, and compares the cost of reintubation and delayed surgical operation, it is difficult to weigh in on the cost benefit advocated in the literature.
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