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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 2  |  Page : 110-114

Ultra-fast-tracking in cardiac anesthesia “Our Experience” in a rural setup


Department of Cardiac Anesthesia, Jawaharlal Nehru Medical College, DMIMS (DU), Wardha, Maharashtra, India

Date of Web Publication8-Sep-2017

Correspondence Address:
Manisha Taware
Jawaharlal Nehru Medical College, DMIMS (DU), Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_56_17

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  Abstract 

Background: Fast-track cardiac anesthesia refers to extubation within 6 h of the end of surgery, whereas ultra-fast-track anesthesia (UFTA) refers to extubation within 2 h of the end of surgery. Objectives: We have tested a protocol for early extubation to see safety, efficacy of ultra-fast tracking, and its cost containment in the present study of forty patients in cardiac surgery department in a tertiary care rural center. Materials and Methods: We have observed in our study the outcome of UFTA on a set of forty patients posted for cardiac surgery, using a protocolized approach and have prospectively noted the duration of mechanical ventilation, extubation time, length of Intensive Care Unit (ICU) stay, rate of re intubation, and other complication. Results: Extubation could be achieved within 30 min in 29 patients (72.5%). Mean length of ICU stay could be cut to 1.6 days (39 h). 55% patients could be mobilized on postoperative day 1, With approximate cost savings of 5000 rupees/patient/day. No cases of reintubation or serious complications noted. Conclusion: Ultra-fast-tracking is found to be feasible in our cardiac surgical setup. It is safe in all age groups, with proper selection of cases and rational utilization of available resources, besides it is found to be cost-effective.

Keywords: Cardiac anesthesia, extubation, ultra-fast-tracking


How to cite this article:
Taware M, Sonkusale M, Deshpande R. Ultra-fast-tracking in cardiac anesthesia “Our Experience” in a rural setup. J Datta Meghe Inst Med Sci Univ 2017;12:110-4

How to cite this URL:
Taware M, Sonkusale M, Deshpande R. Ultra-fast-tracking in cardiac anesthesia “Our Experience” in a rural setup. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2017 Nov 22];12:110-4. Available from: http://www.journaldmims.com/text.asp?2017/12/2/110/214193


  Introduction Top


Fast tracking implies implementation of perioperative patient care programs that ultimately reduce the time of hospital discharge and early resumption of activities after any major or a minor surgical procedure. It is gaining importance because of rapid mobilization, less morbidity, early discharge, better patient comfort, and economic concerns. Fast-track cardiac anesthesia (FTCA) refers to extubation within 6 h of the end of surgery, whereas ultra-fast-track anesthesia (UFTA) refers to extubation within 2 h of the end of surgery.

Aims

We have prepared a protocol of perioperative management in cardiac anesthesia for ultra-fast-tracking. Our aim was to test the feasibility of this protocol for UFTA in our cardiac center.

Objectives

Following parameters were applied for testing the protocol.

(1) Time to extubation, (2) Length of Intensive Care Unit (ICU) stay, (3) Incidence of complications, (4) Cost-effectiveness of this technique.


  Materials and Methods Top


It is a prospective observational (case series) done in the period of April 2013–October 2013 on a set of forty patients posted for cardiac surgery.

Inclusion criteria

  • Age 1–70 years
  • Cross-clamp time <120 min
  • Ejection fraction (EF) >30%
  • Open heart surgical cases, off pump coronary artery bypass graft (CABG).


Exclusion criteria

  • Poor left ventricular function with intraaortic balloon pump support
  • Comorbidities + (hepatic or renal failure, creatinine >1.5, h/o convulsions, tuberculosis, or asthma)
  • Emergency surgery
  • Combined procedure (i.e., CABG + other heart/vascular procedure)
  • Redo surgery.


Anesthesia protocol

On-table extubation criteria

  • Patient awake, responsive, and cooperative
  • Vital capacity >6 ml/kg
  • Transesophageal echocardiography (TEE) findings are normal.
  • PaO2>80 mmHg on FiO2≤0.5, pH 7.35–7.45
  • Temperature >36.5°C
  • Absence of uncontrolled dysrhythmia
  • Minimal chest tube drainage.


Note: If on-table extubation is not achieved à patient was extubated within 2 h, postoperatively if fulfilling the above criteria.

We have implemented a multidisciplinary approach wherein the surgeons' cooperation in view of fast and precise surgery, anesthetist for their selected anesthetic technique, and perfusionist for some favorable modifications in cardiopulmonary bypass (CPB).


  Results Top


Extubation could be achieved within 30 min in 29 patients (72.5%), 19 out of 22 congenital heart disease could be extubated on table (86%). Two cases could not be extubated early within 2 h. Reasons for late extubation were high-surgical drains, which was not related to our anesthetic technique. Mean length of ICU stay could be cut down to 1.8 days. 40% patients mobilized on the day of surgery. 55% patients could be mobilized on postoperative day 1and remaining 5% on day 2. No cases of reintubation or serious complications except two cases which had ICU psychosis and one case having atrial fibrillation which was manageable, with approximate cost savings of 5000 rupees/patient/day.

The results of the study are depicted in figure formats [Figure 1], [Figure 2], [Figure 3] and tabular formats [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]
Figure 1: Age distribution

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Figure 2: Case distribution

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Figure 3: Mobilization

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Table 1: Anesthesia protocol

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Table 2: Postoperative period

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Table 3: Demographic data

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Table 4: Congenital heart disease

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Table 5: Cardiopulmonary bypass data

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Table 6: Extubation time

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Table 7: Variables and number of cases

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Table 8: Complications

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Table 9: Average length of stay in Intensive Care Unit

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Table 10: Economics of fast tracking

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Table 11: Responsibilities and assignments

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Table 12: Suggestions in Cardiac Anaesthesia

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  Discussion Top


Cardiac anesthesia like most other medical disciplines has undergone many transformation over the years. High-dose opioids have been traditionally used in cardiac anesthesia mainly because of the cardio stability that they provide. It requires postoperative mechanical ventilation until the patient's blood gas status, temperature, and hemodynamics were stabilized. In the 1990s, due to financial constraints on medical services, the focus of cardiac anesthesia has shifted to low-opioid techniques, wide use of short-acting anesthetic drugs, and multimodal analgesic techniques. This facilitated faster recovery, early extubation, and shorter ICU stay and reduction in cost. Fast tracking has become a relatively accepted method now in cardiac anesthesia.

As quoted by Barash et al., “in this era of cost containment any technique that allows maximal use of resources without jeopardizing patients safety is welcome.”[1] This statement is even more true today when hospitals are struggling with increasing medical expenses. Although fast-track anesthesia was introduced in 1990s, still large multicentre trials confirming its potential benefits have not being developed. Thus, concerns about the safety of these technique still remain [Figure 1], [Figure 2], [Figure 3].

This study was carried out in the operating rooms (OR) and ICU of our center, belonging to a rural hospital, which has a high-cardiac patients flow particularly from a low-socioeconomic status; Hence, we needed ICU beds, reduction in cost of surgery, and reduction in hospital stay. Such a protocol was the need of the hour. Our approach was goal directed with favorable cooperation from the surgeon (speed and precision, use of standardized surgical technique, minimizing cross clamp time, adequate hemostasis, and less surgical errors) and that of perfusionist team also.

The role of cardiac anesthetist is the key to successful outcome that includes from patient selection, avoiding unnecessary us age of inotropes and blood products, efficient pain relief, and availability round the clock.

Our anesthetic strategies included the following:

We have followed safe CPB techniques, particularly the use of blood cardioplegia and maintenance of normothermia. Such modifications have been shown to reduce extubation time and lower hospital and ICU stay.[2] We have included only cases which do not have prolonged cross-clamp time, <120 min as shown in our CPB data.

Use of nonopioid analgesia (dexmedetomidine, paracetamol) in postoperative period is always beneficial for early mobilization and patient comfort. We have found that faster mobilization is possible with use of less sedation in postoperative period which is a psychological boost the patient and their relatives. We have avoided thoracic epidural techniques which has reduced cost. Use of caudal blocks in pediatric patients has resulted in adequate analgesia in perioperative period reducing opioid dose.

Pediatric patients have been shown to benefit from early extubation. Extubation by UFTA mode in children has been known to reduce ICU stay and lesser use of hospital resources.[3] Most children undergoing congenital heart surgery can be extubated in OR. Early extubation is associated with low-morbidity rates and shorter length of ICU stay.[4] A study on intraoperative anesthetic management directed to early extubation in pediatric cardiac surgery has been shown to decrease pediatric ICU stay.[5]

Although fast tracking in pediatric congenital heart disease cases has been practiced safely significant individual and institutional concerns about the safety still exists. In this study, we have successfully fast-tracked pediatric surgery cases (86% on table extubation).

Whereas adult cardiac cases are being done without adverse outcome by fast-track anesthesia technique.[6] In the elderly patients, UFTA is been found to be safe with careful selection of cases.[7] In our study, we have included patients of different age group. Elderly patients included in our study are the one having EF >30% and no comorbidities.

In an earlier study, immediate extubation has not been shown to cause any complications when compared to use of conventional strategies in other patients.[8] Reintubation was not done in any of our UFTA patient. Studies have shown no difference in reintubation rates in fast-tracked patients compared to conventional management.[9],[10] Reported rate of reintubation following early extubation in patients with congenital heart disease is typically very low, 2%–3%.[2] There is no evidence of increased morbidity or mortality with FTCA technique as compared to traditional high-dose opioid technique.[11] Studies have proven that extubation in the OR can be safely performed in cardiac surgery cases without any increase in morbidity and mortality [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].[12]

Benefits of early extubation, particularly in CABG patients, include improved cardiac function and reduction in ICU stay, thus saving patient cost,[13] shorter length of hospital stay, and cost savings compared with national data were observed after implementation of fast tracking in cardiac anesthesia.[14] Cheng et al. designed a prospective randomized trial to evaluate the total cost savings of early extubation which was about 9% per CABG case in uncomplicated surgeries.[15] As observed in the study, it is definitely a cost-effective technique [Table 7]. A total of forty patients were observed in our study, of which 38 patients were successfully extubated within 2 h of the surgery [Table 8], [Table 9], [Table 10], [Table 11], [Table 12].

Limitations of this case series

  • Number of cases were limited
  • Long-term risk not observed.



  Conclusion Top


Ultra-fast-tracking was found feasible in our rural center which is still developing. With proper selection of cases, rational utilization of available resources (drugs, TEE, trained theater, and nursing staff) and management as a teamwork resulted in successful outcome. We found it applicable in a wide range of age group, pediatric as well elderly. Excellent outcome i/v/o faster patient mobilization, improved patient comfort and cooperation, and reduced postoperative morbidity. Cost containment of this technique deserves particular mention as our medical services are increasingly struggling with limited resources as opposed to ever increasing patient load.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Barash PG, Lescovich F, Katz JD, Talner NS, Stansel HC Jr. Early extubation following pediatric cardiothoracic operation: A viable alternative. Ann Thorac Surg 1980;29:228-33.  Back to cited text no. 1
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2.
Oxelbark S, Bengtsson L, Eggersen M, Kopp J, Pedersen J, Sanchez R, et al. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 2001;19:460-3.  Back to cited text no. 2
    
3.
Garg R, Rao S, John C, Reddy C, Hegde R, Murthy K, et al. Extubation in the operating room after cardiac surgery in children: A prospective observational study with multidisciplinary coordinated approach. J Cardiothorac Vasc Anesth 2014;28:479-87.  Back to cited text no. 3
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4.
Harris KC, Holowachuk S, Pitfield S, Sanatani S, Froese N, Potts JE, et al. Should early extubation be the goal for children after congenital cardiac surgery? J Thorac Cardiovasc Surg 2014;148:2642-7.  Back to cited text no. 4
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5.
Preisman S, Lembersky H, Yusim Y, Raviv-Zilka L, Perel A, Keidan I, et al. Arandomized trial of outcomes of anesthetic management directed to very early extubation after cardiac surgery in children. J Cardiothorac Vasc Anesth 2009;23:348-57.  Back to cited text no. 5
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6.
Svircevic V, Nierich AP, Moons KG, Brandon Bravo Bruinsma GJ, Kalkman CJ, van Dijk D, et al. Fast-track anesthesia and cardiac surgery: A retrospective cohort study of 7989 patients. Anesth Analg 2009;108:727-33.  Back to cited text no. 6
    
7.
Borracci RA, Ochoa G, Ingino CA, Lebus JM, Grimaldi SV, Gambetta MX, et al. Routine operation theatre extubation after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg 2016;22:627-32.  Back to cited text no. 7
    
8.
Chong JL, Grebenik C, Sinclair M, Fisher A, Pillai R, Westaby S, et al. The effect of a cardiac surgical recovery area on the timing of extubation. J Cardiothorac Vasc Anesth 1993;7:137-41.  Back to cited text no. 8
    
9.
Bansal S, Thai HM, Hsu CH, Sai-Sudhakar CB, Goldman S, Rhenman BE. fast track extubation post coronary artery bypass graft: A retrospective review of predictors of clinical outcomes. World J Cardiovasc Surg 2013;3:81-6.  Back to cited text no. 9
    
10.
Amirghofran AA, Rayatpisheh M, Rayatpisheh S, Kaviani M. A comparative study of immediate and late extubation after open heart surgery. Iran Cardiovasc Res J 2007;1:42-7.  Back to cited text no. 10
    
11.
Myles PS, Daly DJ, Djaiani G, Lee A, Cheng DC. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology 2003;99:982-7.  Back to cited text no. 11
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12.
Rodriguez Blanco YF, Candiotti K, Gologorsky A, Tang F, Giquel J, Barron ME, et al. Factors which predict safe extubation in the operating room following cardiac surgery. J Card Surg 2012;27:275-80.  Back to cited text no. 12
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13.
Miyamoto T, Kimura T, Hadama T. The benefits and new predictors of early extubation following coronary artery bypass grafting. Ann Thorac Cardiovasc Surg 2000;6:39-45.  Back to cited text no. 13
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14.
Cheng DC, Karski J, Peniston C, Raveendran G, Asokumar B, Carroll J, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial. Anesthesiology 1996;85:1300-10.  Back to cited text no. 14
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15.
Lawrence EJ, Nguyen K, Morris SA, Hollinger I, Graham DA, Jenkins KJ, et al. Economic and safety implications of introducing fast tracking in congenital heart surgery. Circ Cardiovasc Qual Outcomes 2013;6:201-7.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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