Fast-Tracking Cardiac Surgery

Authors

  • Ravi U. Pande
  • Nader D. Nader
  • Giuseppe D' Ancona
  • Nader D. Nader
  • Harry W. Donias

DOI:

https://doi.org/10.1532/hsf.1186

Abstract

A "fast track" approach to cardiac surgery can be defined as a perioperative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital. Although highly individualized among the various heart surgery centers, the fast-track process is a team activity. It requires a team of health care providers to interact with the patient at various phases, from admission to discharge. The necessary elements of the fast-track program are choice and the titration of short-acting anesthetic drugs, standardized surgical procedures, early extubation, rewarming and sustained postoperative normothermia, postoperative pain control, early ambulation, alimentation and discharge, and follow-up after discharge. We review the current approaches to some of these aspects of patient care.

References

Sanchez R, Nygard E. 1998. Epidural anesthesia in cardiac surgery: is there an increased risk? J Cardiothorac Vasc Anesth 12:170-3.nStraka Z, Brucek P, Vanek T, Votava J, Widimsky P. 2002. Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. Ann Thorac Surg 74:1544-7.nSvedjeholm R, Ekroth R, Joachimsson PO, Ronquist G, Svensson S, Tyden H. 1991. Myocardial uptake of amino acids and other substrates in relation to myocardial oxygen consumption four hours after cardiac operations. J Thorac Cardiovasc Surg 101:688-94.nSwenson JD, Hullander RM, Wingler K, Leivers D. 1994. Early extubation after cardiac surgery using combined intrathecal sufentanil and morphine. J Cardiothorac Vasc Anesth 8:509-14.nTurnbull KW. 1996. Neuraxial anesthesia is contraindicated in patients undergoing heparinization for surgery. Con: neuraxial block is useful in patients undergoing heparinization for surgery. J Cardiothorac Vasc Anesth 10:961-2.nWestaby S. 1987. Organ dysfunction after cardiopulmonary bypass: a systemic inflammatory reaction induced by the extracorporeal circuit. Intensive Care Med 13:89-95.nAun C, Thomas D, St John-Jones L, Colvin MP, Savege TM, Lewis CT. 1985. Intrathecal morphine in cardiac surgery. Eur J Anaesthesiol 2:419-26.nBarham NJ, Boomers OW, Sherry KM, Locke TJ. 1998. Myocardial ischaemia during tracheal extubation in patients after cardiac surgery: an observational study. Br J Anaesth 80:832-3.nBell J, Sartain J, Wilkinson GA, Sherry KM. 1994. Propofol and fentanyl anaesthesia for patients with low cardiac output state undergoing cardiac surgery: comparison with high-dose fentanyl anaesthesia. Br J Anaesth 73:162-6.nBenetti FJ, Naselli G, Wood M, Geffner L. 1991. Direct myocardial revascularization without extracorporeal-circulation: experience in 700 patients. Chest 100:312-6.nBerry PD, Thomas SD, Mahon SP, et al. 1998. Myocardial ischaemia after coronary artery bypass grafting: early vs late extubation. Br J Anaesth 80:20-5.nBoer F, Ros P, Bovill JG, et al. 1990. Effect of propofol on peripheral vascular resistance during cardiopulmonary bypass. Br J Anaesth 65:184-9.nBorst C, Gründeman PF. 1999. Minimally invasive coronary artery bypass grafting: an experimental perspective. Circulation 99:1400-3.nDonias HW, Karamanoukian HL. 2002. The use of alpha2-agonists during off-pump coronary artery bypass and the effects of hypothermia. J Cardiothorac Vasc Anesth 16:135-6.nDoty JR, Fonger JD, Salazar JD, Walinsky PL, Salomon NW. 1999. Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. J Thorac Cardiovasc Surg 117:873-80.nEngelman RM, Rousou JA, Flack JE, et al. 1994. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 58:1742-6.nEngoren M, Luther G, Fenn-Buderer N. 2001. A comparison of fentanyl, sufentanil, and remifentanil for fast-track cardiac anesthesia. Anesth Analg 93:859-64.nEngoren MC, Kraras C, Garzia F. 1998. Propofol-based versus fentanylisoflurane-based anesthesia for cardiac surgery. J Cardiothorac Vasc Anesth 12:177-81.nFitzpatrick GJ, Moriarty DC. 1988. Intrathecal morphine in the management of pain following cardiac surgery: a comparison with morphine i.v. Br J Anaesth 60:639-44.nFrank SM, Fleisher LA, Breslow MJ, et al. 1997. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA 277:1127-34.nMohr FW, Falk V, Diegeler A, Walther T, van Son JAM, Autschbach R. 1998. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg 115:567-74.nMyles PS, Buckland MR, Weeks AM, et al. 1997. Hemodynamic effects, myocardial ischemia, and timing of tracheal extubation with propofol-based anesthesia for cardiac surgery. Anesth Analg 84:12-9.nNesher N, Insler SR, Sheinberg N, et al. 2002. A new thermoregulation system for maintaining perioperative normothermia and attenuating myocardial injury in off-pump coronary artery bypass surgery. Heart Surg Forum 5:373-80.nOkutani R, Philbin DM, Rosow CE, Koski G, Schneider RC. 1988. Effect of hypothermic hemodilutional cardiopulmonary bypass on plasma sufentanil and catecholamine concentrations in humans. Anesth Analg 67:667-70.nOnishchuk JL, Carlsson C. 1992. Epidural hematoma associated with epidural anesthesia: complications of anticoagulant therapy. Anesthesiology 77:1221-3.nPage GG, Ben-Eliyahu S. 1997. The immune-suppressive nature of pain. Semin Oncol Nurs 13:10-5.nRichardson J, Bresland K. 1998. The management of postsurgical pain in the elderly population. Drugs Aging 13:17-31.nWhite PF. 1995. Management of postoperative pain and emesis. Can J Anaesth 42:1053-5.nKaplan M, Kut MS, Yurtseven N, Cimen S, Demirtas MM. 2002. Accelerated recovery after cardiac operations. Heart Surg Forum 5:381-7.nKaragoz HY, Sonmez B, Bakkaloglu B, et al. 2000. Coronary artery< bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 70:91-6.nKehlet H. 1982. The endocrine-metabolic response to postoperative pain. Acta Anaesthesiol Scand Suppl 74:173-5.nKirklin JK, Blackstone EH, Kirklin JW. 1987. Cardiopulmonary bypass: studies on its damaging effects. Blood Purif 5:168-78.nKrohn BG, Kay JH, Mendez MA, Zubiate P, Kay GL. 1990. Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg100:194-7.nLake CL. 2000. Fast tracking the pediatric cardiac surgical patient. Paediatr Anaesth 10:231-6.nLeicht C. 1993. Epidural hematoma associated with epidural anesthesia: complications of anticoagulant therapy. Anesthesiology 78:1188.nLumpkin MM. 1998. FDA public health advisory. Anesthesiology 88:27A-8A.nMack M, Acuff T, Yong P, Jett GK, Carter D. 1997. Minimally invasive thoracoscopically assisted coronary artery bypass surgery. Eur J Cardiothorac Surg 12:20-4.nMangano DT, Siliciano D, Hollenberg M, et al. 1992. Postoperative myocardial ischemia: therapeutic trials using intensive analgesia following surgery: The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology 76:342-53.nMangano DT. 1985. Biventricular function after myocardial revascularization in humans: deterioration and recovery patterns during the first 24 hours. Anesthesiology 62:571-7.nMessent M, Sullivan K, Keogh BF, Morgan CJ, Evans TW. 1992. Adult respiratory distress syndrome following cardiopulmonary bypass: incidence and prediction. Anaesthesia 47:267-8.nMoat NE, Rebuck N, Shore DF, Evans TW, Finn AH. 1993. Humoral and cellular activation in a simulated extracorporeal circuit. Ann Thorac Surg 56:1509-14.nMohr FW, Falk V, Diegeler A, Autschbach R. 1999. Computer-enhanced coronary artery bypass surgery. J Thorac Cardiovasc Surg 117:1212-4.nBuffolo E, de Andrade CS, Branco JN, Teles CA, Aguiar LF, Gomes WJ. 1996. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 61:63-6.nCalafiore AM, Giammarco GD, Teodori G, et al. 1996. Left anterior descending coronary artery grafting via left anterior small thoracotomynwithout cardiopulmonary bypass. Ann Thorac Surg 61:1658-65.nCarpenter RL, Abram SE, Bromage PR, Rauck RL. 1996. Consensus statement on acute pain management. Reg Anesth 21:152-6.nCarpentier A, Loulmet D, Aupecle B, Berrebi A, Relland J. 1999. Computer-assisted cardiac surgery. Lancet 353:379-80.nChaney MA. 1997. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 84:1211-21.nCheng DC, Karski J, Peniston C, et al. 1996. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: a prospective, randomized, controlled trial. Anesthesiology 85:1300-10.nCheng DCH, Karski J, Peniston C, et al. 1996. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac CardiovascSurg 112:755-64.nChitwood WR Jr, Nifong LW, Elbeery JE, et al. 2000. Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da vinci surgical system. J Thorac Cardiovasc Surg 120:1171-2.nCzibik G, D'Ancona G, Donias HW, Karamanoukian HL. 2002. Robotic cardiac surgery: present and future applications. J Cardiothorac Vasc Anesth 16:495-501.nde Leon-Casasola OA, Lema MJ. 1994. Epidural bupivacaine/sufentanil therapy for postoperative pain control in patients tolerant to opioid and unresponsive to epidural bupivacaine/morphine. Anesthesiology 80:303-9.nde Leon-Casasola OA, Parker B, Lema MJ, Harrison P, Massey J. 1994. Postoperative epidural bupivacaine-morphine therapy: experience with 4,227 surgical cancer patients. Anesthesiology 81:368-75.nDickman CA, Shedd SA, Spetzler RF, Shetter AG, Sonntag VK. 1990. Spinal epidural hematoma associated with epidural anesthesia: complications of systemic heparinization in patients receiving peripheral vascular thrombolytic therapy. Anesthesiology 72:947-50.nDjaiani GN, Hall J, Pugh S, Peaston RT. 2001. Vital capacity inhalation induction with sevoflurane: an alternative to standard intravenous induction for patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 15:169-74.nGlass PS, Hardman D, Kamiyama Y, et al. 1993. Preliminary pharmacokinetics and pharmacodynamics of an ultra-short-acting opioid: remifentanil (GI87084B). Anesth Analg 77:1031-40.nGrady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. 1999. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia: Mayo Perioperative Outcomes Group. Anesth Analg 88:388-92.nHaljamae H. 1996. Thromboprophylaxis, coagulation disorders, and regional anaesthesia. Acta Anaesthesiol Scand 40:1024-40.nHeller PH, Perry F, Naifeh K, Gordon NC, Wachter-Shikura N, Levine J. 1984. Cardiovascular autonomic response during preoperative stress and postoperative pain. Pain 18:33-40.nHorlocker TT, McGregor DG, Matsushige DK, Chantigian RC, Schroeder DR, Besse JA. 1997. Neurologic complications of 603 consective continuous spinal anesthetics using macrocatheter and micro-catheter techniques: Perioperative Outcomes Group. Anesth Analg 84:1063-70.nJacobson L, Chabal C, Brody MC. 1988. A dose-response study of intrathecal morphine: efficacy, duration, optimal dose, and side effects. Anesth Analg 67:1082-8.nJacobson L, Chabal C, Brody MC, Ward RJ, Ireton RC. 1989. Intrathecal methadone and morphine for postoperative analgesia: a comparison of the efficacy, duration, and side effects. Anesthesiology 70:742-6.nJacobson L, Chabal C, Brody MC, Ward RJ, Wasse L. 1990. Intrathecal methadone: a dose-response study and comparison with intrathecal morphine 0.5 mg. Pain 43:141-8.nAhonen J, Olkkola KT, Verkkala K, Heikkinen L, Jarvinen A, Salmenpera M. 2000. A comparison of remifentanil and alfentanil for use with propofol in patients undergoing minimally invasive coronary artery bypass surgery. Anesth Analg 90:1269-74.nAnderson MB, Kwong KF, Furst AJ, Salerno TA. 2001. Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient. Eur J Cardiothorac Surg 20:415-7.n

Published

2005-02-07

How to Cite

Pande, R. U., Nader, N. D., Ancona, G. D., Nader, N. D., & Donias, H. W. (2005). Fast-Tracking Cardiac Surgery. The Heart Surgery Forum, 6(4), 244-248. https://doi.org/10.1532/hsf.1186

Issue

Section

Articles

Most read articles by the same author(s)