A Coronary Artery Bypass “Fast-Track” Protocol Is Practical and Realistic in a Rural Environment

Quigley, Robert L.; Reitknecht, Felice

doi:10.1016/s0003-4975(97)00717-0

Cited by 27 publications

(10 citation statements)

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“…Only the optimal utilisation of available resources, such as the multiple daily use of an intensive care bed or the optimised design of surgery schedules including the fast-track concept can satisfy the growing demands and expectations of today’s heart surgery patients. Only considerable improvements in surgical, extracorporeal, anesthesiological and perioperative management have created the possibility of this fast-track approach [1-4,7,13,23-25]. The fast-track concept, however, is not subject to a rigid, uniform definition, but rather reflects the aspiration to transform established conventional techniques or procedures into modern patient management.…”

Section: Discussionmentioning

confidence: 99%

“…Besides shortening ICU occupancy times, which is undisputedly the limiting factor and the bottleneck in the care of heart surgery patients, the rising costs can be contained by shortening the overall hospitalisation period [16,19,20]. The precondition for introducing fast-track concepts was the continuous further development of existing surgical, cardiac technological, anesthesiological and postoperative management [1-4,7,13,23-25]. The introduction of short-acting substances such as propofol or remifentanil as well as inhalation anesthetics such as sevoflurane has contributed decisively to changing monitored anesthesia care.…”

Section: Introductionmentioning

confidence: 99%

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Risk factor analysis for fast track protocol failure

Kiessling

Huneke

Reyher

et al. 2013

J Cardiothorac Surg

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BackgroundThe introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.Methods229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.ResultsOver the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).ConclusionRe-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Risk factor analysis for fast track protocol failure

Kiessling

Huneke

Reyher

et al. 2013

J Cardiothorac Surg

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“…Nevertheless, for more than 15 years we have used predominantly OPCAB by LAT approach with good results. Unfortunately, we did not include our cases-series before 2010 In conclusion, the management described in this study allows very rapid recovery as well as a short ICU and Hosp-LOS, offering the possibility of cost reduction; this fact has permitted us to help a vast number of cardiac patients at our centre for years [32]. In general, age >80 y.o, female sex, severity of EuroSCORE and ≥ 2 PRBCs transfusion were risk factor for UTF-failure and prolonged Hosp-LOS .However, our study has developed two predictive models with high diagnostic validity for UFT-failure and prolonged Hosp-LOS that include as stronger perioperative risk factor transfusion of ≥2 PRCB, severity of angina pectoris, Redo, duration of surgery >3 hrs and ICU-LOS >24 hrs.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Risk Factors and Predictive Model Proposal of Ultra-Fast-Track Failure and Prolonged Hospital Length of Stay in a Preliminary Protocol of Enhanced Recovery after Off-Pump Coronary Artery Bypass Grafting by Left Anterolateral Thoracotomy Approach (ERAS)

Munoz-Galarce¹,

Munoz-Monaco²,

Guida³

et al. 2018

J Perioper Med

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Background: The use of Ultra-fast-track (UFT) management in cardiac surgery may shorten hospital length of stay (Hosp-LOS) when is part of a protocol of enhance recovery after surgery (ERAS). Methods: We retrospectively analyzed the data of the patients undergoing elective off-pump coronary artery bypass grafting (OPCAB) using UFT under a pilot program of ERAS at a Venezuelan nonprofit cardiac center from 2010 to 2014. The primary goal was to describe the short-term outcome of a consecutive case-series managed with desfluraneremifentanil-intercostals nerve block for OPCAB by Left-Anterolateral Thoracotomy and followed up by multidisciplinary enhance recovery pathway. The secondary goals were to identify perioperative predictors for UTF-failure and Hosp-LOS >4 days and try to propose a predictive risk model from the variables involved. Results: 1,943 bypasses were performed on 673 patients. 61.5 ± 9.5 years old, EuroSCORE was 5.2 ± 4.1. 97.8% was extubated in Operating Room (UFT-success) and 2.2% extubated in the intensive care unit (UFT-failure). The reintubation rate was 0.5%. Patients had an Intensive Care Unit length of stay (ICU-LOS) of 29 ± 4.2 hours; 636 patients (94.5%) had ICU-LOS ≤ 24 h, 2.1% readmitted to ICU. The Hosp-LOS after discharge from ICU was 50.5 ± 9.9 hours, 633 (94.1%) had Hosp-LOS ≤ 4 days. Univariate analysis revealed as independent risk factors for UFT-failure: age, female sex, EuroSCORE, Severity of Angina Pectoris, EF <30%, Redo, COPD, PRBC transfusion, use of elective IABP and duration of surgery(t-Qx).However, multivariate logistic regression analysis and backward elimination method found as strong risk factors for UFT-failure: transfusion of ≥ 2 PRCB Adjusted Odds Ratio (AOR=6.02) (95%CI) (p<0.05), t-Qx 3-4 hrs, (AOR=77.3)(95%CI) (p <0.001) and t-Qx > 4 hrs, (AOR=157.5) (95%CI) (p <0.001). Univariate analysis revealed as independent risk factors for Hosp-LOS >4 days : Age>80 y-old, female sex, NYHA>III, EuroSCORE, severity of Angina pectoris , EF <30%, Redo, renal failure, IABP, PRCB transfusion, UFT-failure, t-Qx and ICU-LOS (p<0.001). Multivariate logistic regression analysis and backward elimination method found as strong risk factors for Prolonged Hosp-LOS (>4 days) : Redo (AOR=7.68) (95%CI), t-Qx>3 hrs (AOR>74) (95%CI) (p<0.001) and ICU-LOS >24 hrs (AOR=29.3) (95%CI) (p<0.001). Conclusions: As most patients were extubated in the Op.Room, had short ICU-LOS (<24 h) and short Hospital-LOS (≤ 4 days). UTF appears to have clinical benefits in this setting. In general, age>80 y.o , female sex, severity of EuroSCORE and ≥ 2 PRBCs transfusion were risk factor for UTF-failure and prolonged Hosp-LOS. However, the stronger predictive factors for UTF-failure and Hosp-LOS>4 days were transfusion of ≥ 2 PRCB, Redo, duration of surgery >3 h and ICU-LOS >24 h. Prospective studies would better elucidate the risk factors for longer Hospital-LOS and attendant morbidities.

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“…Hierdurch konnte die Morbidität von 20-30 % auf unter 10 % gesenkt werden [17]. Aber auch bei vielen Eingriffen in der Allgemein-, Viszeral-, Thorax-und Herzchirurgie [15,18], der Orthopädie, der Urologie und Gynäkologie kommen solche strukturierten Behandlungskonzepte inzwischen zur Anwendung [8]. Wichtige Bestandteile dieser Konzepte sind eine eingehende präoperative Patientenschulung, eine möglichst atraumatische Operation über einen limitierten Zugang, eine optimierte Anästhesie mit effektiver Analgesie, ein frühzeitiger enteraler Kostaufbau und eine beschleunigte postoperative Mobilisation [8,17].…”

Section: Abstract !unclassified