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)

Abstract

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.