Fast-track cardiac anaesthesia and early extubation

State of the Art Surgical Coronary Revascularization ◽

10.1093/med/9780198758785.003.0032 ◽

2021 ◽

pp. 174-180

Author(s):

Janet Martin ◽

Davy Cheng

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cardiac Surgery ◽

Fast Track ◽

Interdisciplinary Approach ◽

Cardiac Care ◽

Early Extubation ◽

Cardiac Anaesthesia ◽

Balanced Anaesthesia ◽

Intravenous Anaesthetics

‘Fast-track’ cardiac anaesthesia and recovery is the term given to a multicomponent intervention during cardiac surgery and postoperatively, with the ultimate goal of early extubation (within 1–6 hours) in order to reduce duration of mechanical ventilation, length of stay in the intensive care unit, and overall resource utilization. Key components of fast-track cardiac care include balanced anaesthesia (low-dose opioids together with inhaled or intravenous anaesthetics) and a time-directed extubation protocol. Fast-track cardiac care requires an interdisciplinary approach to anaesthesia during surgery, as well as a coordinated approach after surgery, in order to achieve early extubation and an overall streamlined approach to recovery and hospital discharge.

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Is Fast Track Cardiac Anaesthesia Cost Effective without Compromising Morbidity and Mortality?

JMS SKIMS ◽

10.33883/jms.v20i1.307 ◽

2017 ◽

Vol 20 (1) ◽

pp. 22-30

Author(s):

Puja Vimesh ◽

Shyam Singh ◽

Shivani Mehta ◽

Ramesh Chander

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Fast Track ◽

Open Heart ◽

Aortic Cross Clamp Time ◽

Aortic Cross Clamp ◽

Cardiac Anaesthesia ◽

Ventilation Duration ◽

Room Time

Background: With the evolution of anaesthesia and surgical procedures, fast track cardiac anaesthesia (FTCA) has gained an increased interest, mainly based on the possibility of reducing health costs without compromising patient care and wellbeingObjective:The purpose of this study was to evaluate different durations in Early Extubation (EE) like Aortic Cross Clamp Time (ACCT),Cardiopulmonary bypass time (CPB Time), Mechanical Ventilation Duration (MVD), Operation Room time (ORT), Intensive Care Unit (ICU) and post ICU time as well as Total Hospital Stay Time (THST) in open heart procedures. This has been done to co-relate FTCA with lowering of hospital expenditure without compromising with morbidity and mortality.Methods: This is a “Prospective Cohort Study” comprising of a group of 80 patients who underwent open heart surgery in a Rural Cardiac Center, in 2014. After FTCA and surgical technique, we reviewed the duration of mechanical ventilation, length of Intensive Care Unit stay, reintubation, and incidence of in-hospital mortality and followed our cases prospectively till discharge from the hospital.Results : The group of Fast Track Cardiac Anaesthesia comprised of 80 patients. Range of ventilation duration (VD ) was 2-4 hours in 12.8%) to 8-10 hours in 9% cases; Aortic cross clamp time (ACCT) in minutes was 25-49 in 35% cases to 100-124 in 2.7% of cases. Similarly Range of Cardio- pulmonary Bypass Time (CPBT) in minutes 40-69 minutes in 21.6% to 160-190 minutes in 4% cases, surgery time (ST) in hours was 2-3 in 7.5% cases to 6-8 in 28.8 % cases; operation room time (ORT) in hours was 2-4 in 3.8% to 6-8 hours in 28.8% patients; ionotropic duration (ID) in hours was 2-5 in 20% to 18 to 24 hours in 6.3% cases; Intensive Care Unit (ICU) stay in days was 1-2 days in 66.3% to 3-4 days in 3.8% cases ;and post ICU stay in days was 2-3 in 1.3% to 6-7 in 87.5% patients.Total hospital stay in days was 4-6 days in 4 case, 7-9 in 40 cases and 10-12 days in 36 cases.Reintubation was done only in 1 out of 78 cases. In our study there was no mortality. Conclusions :Fast track Cardiac anaesthesia is suitable with applied anesthetic technique in our centre. However there exists relatively small risk of re-intubation (1.3%). Small sample size is pointer towards a little lack of statistical strength of the study. JMS 2017; 20(1):22-30

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Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol

Critical Care Nurse ◽

10.4037/ccn2021189 ◽

2021 ◽

Vol 41 (3) ◽

pp. 14-24

Author(s):

Myra F. Ellis ◽

Heather Pena ◽

Allen Cadavero ◽

Debra Farrell ◽

Mollie Kettle ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Fast Track ◽

Early Extubation ◽

Control Approach ◽

Prolonged Intubation ◽

Care Processes ◽

Provider Practice ◽

The Impact

Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

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Early axtubation in cardiac surgery

Medicinski pregled ◽

10.2298/mpns1004183n ◽

2010 ◽

Vol 63 (3-4) ◽

pp. 183-187

Author(s):

Vojislava Neskovic ◽

Predrag Milojevic ◽

Dragana Unic ◽

Ivan Ilic ◽

Nada Popovic

Keyword(s):

Mechanical Ventilation ◽

Cardiac Surgery ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Fast Track ◽

Tracheal Extubation ◽

Early Extubation ◽

Cardiac Anesthesia ◽

Thoracic Epidural ◽

High Thoracic Epidural

Introduction An early extubation in cardiac surgery (fast track cardiac anesthesia) refers to mechanical ventilation during 1-6 hours after the intervention, the extubation criteria being the same as for any other surgery. Different protocols have been established for managing patients undergoing fast track anesthesia, with high-thoracic epidural anesthesia being increasingly used in the last few years. Material and methods Thirty-five consecutive patients scheduled for OPCAB surgery, who were planned for very fast track cardiac anesthesia (planned extubation within one hour after the end of the operation), were included in the study. Combined high-thoracic epidural and general anesthesia was performed in all patients, with bupivacain as a local anesthetic and inhalational or intravenous anesthetic used for general anesthesia. Results Thirty three of 35 patients (94.3%) were extubated early, with the mean duration of the mechanical ventilation of 56?92 minutes. Very fast track cardiac anesthesia was performed successfully in 24/35 (68,8%) patients; these patients had higher ejection fraction, lower Euroscore, shorter duration of the surgery, and fewer numbers of grafts, as compared to the patients extubated early. Euroscore was the only independent predictor of the early extubation (higher score - longer mechanical ventilation time). Discussion and conclusion Our results suggest that high-toracic epidural anesthesia enables successful early tracheal extubation in the population of patients scheduled for OPCAB cardiac surgery. We had no complications related to this type of anesthesia and very good perioperative results.

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Retrospective analysis of pre- and intraoperative risk factors for readmission to the intensive care unit after fast track cardiac surgery

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0032-1332308 ◽

2013 ◽

Vol 61 (S 01) ◽

Author(s):

AH Kiessling ◽

P Huneke ◽

C Reyher ◽

T Bingold ◽

A Zierer ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Retrospective Analysis ◽

Fast Track

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Readmission to the Intensive Care Unit after Fast-Track Cardiac Surgery: An Analysis of Risk Factors and Outcome according to the Type of Operation

The Heart Surgery Forum ◽

10.1532/hsf98.20101009 ◽

2010 ◽

Vol 13 (4) ◽

pp. E212-E217 ◽

Cited By ~ 13

Author(s):

Fevzi Toraman ◽

Sahin Senay ◽

Umit Gullu ◽

Hasan Karabulut ◽

Cem Alhan

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Fast Track

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What are the benefits and harms of fast-track cardiac care for adults undergoing cardiac surgery?

Cochrane Clinical Answers ◽

10.1002/cca.1517 ◽

2017 ◽

Keyword(s):

Cardiac Surgery ◽

Fast Track ◽

Cardiac Care

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Nursing care in early extubation of cardiosurgical patient: a literature review

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.589 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

G Soave ◽

E Monaco ◽

G Monte ◽

D Gregori ◽

M Martinato

Keyword(s):

Mechanical Ventilation ◽

Nursing Care ◽

Fast Track ◽

Standard Of Care ◽

Early Extubation ◽

Inclusion Criteria ◽

Mechanically Ventilated ◽

Whole Process ◽

Operative Complications ◽

Complications And Mortality

Abstract Introduction Recent studies show that mechanical ventilation (MV) is necessary in only 5-10% of cardiosurgical patients. Thus, this finding denies the theory arguing that a prolonged period of MV (24 hours to 7 days) reduces the risk of complications. Based on these considerations, strategies have developed, i.e. the Fast Track (FT), with the aim of encouraging early extubation (1 to 8 hours after surgery). The objectives of this review are: to verify the effectiveness of FT in terms of reducing post-operative complications, mortality and costs, to analyse the operating procedures and inclusion criteria of each protocol and to outline nursing care in the whole process. Methods Literature search was performed in Cochrane, PubMed, and CINAHL databases. No limits have been applied on study design and publication timespan. Population included adult patients who underwent cardiac surgery with admission to an intensive care unit and were mechanically ventilated. Results 16 articles (including 8 RCT) have been selected. The protocols require that nurses, based on specific parameters, assess the possibility of weaning from sedation and early extubation according to standardised practices. Early extubation decreases the risk of MV-related complications by decreasing hospitalization lenght and thus total costs by at least 3%. No significant differences have been found between FT and standard of care regarding postoperative complications and mortality. Conclusions Taking into account both the proven applicability, safety and efficacy of FT protocols and their high heterogeneity in published studies, that prevent their comparison, further research is needed to identify a reliable algorithm for early extubation based on pre-operative, intraoperative and postoperative data. Key messages Early extubation decreases the risk of MV-related complications by decreasing hospitalization lenght and thus total costs by at least 3%. Recent studies show that mechanical ventilation (MV) is necessary in only 5-10% of cardiosurgical patients.

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