Early Extubation and Fast-Track Anesthetic Technique for Endoscopic Cardiac Surgery
DOI:
https://doi.org/10.1532/HSF98.20091151Abstract
Objective: In this retrospective study, we evaluated the "fast-track" recovery protocol for endoscopic Port Access™ (PA) (Edwards Lifesciences) heart procedures. We also determined which factors and variables are important for the success of immediate extubation at the end of the operation while the patient is still in the operating room (OR).
Methods: In the study, we included 104 patients scheduled for PA heart surgery under cardioplegic arrest. All patients were marked before surgery for the fast-track recovery protocol. If the patients fulfilled the extubation criteria within 10 to 15 minutes after the end of operation, they were extubated in the OR (OR group); the others were transferred to the intensive care unit (ICU) (ICU group) and extubated later. The 2 groups were compared with respect to preoperative and intraoperative variables that could influence early extubation, postoperative complications, duration of ICU stay, and hospital stay.
Results: Seventy-eight patients (75%) were extubated in the OR. The patients from the OR group had significantly lower EuroSCOREs than the patients from the ICU group (P = .025). The variables of vital capacity (P = .001) and forced expiratory volume in the first second (FEV1) (P < .001) were significantly higher preoperatively in the OR group than in the ICU group. There were no significant differences between the groups with respect to intraoperative characteristics. Postoperative complications were fewer in the OR group. The mean duration of ICU stay was significantly shorter in the OR group than in the ICU group (P < .001).
Conclusions: Immediate extubation in the OR after endoscopic cardiac procedures is safe and possible for the majority of patients. The preoperative patient characteristics of Euro-SCORE, vital capacity, and FEV1 influence the success of ontable extubation.
References
Alhan C, Toraman F, Karabulut EH, et al. 2003. Fast track recovery of high risk coronary bypass surgery patients. Eur J Cardiothorac Surg 23:678-83.nAntonic M, Gersak B. 2007. Renal function after port access and median sternotomy mitral valve surgery. Heart Surg Forum 10:E401-7.nBando K, Sun K, Binford SB, Sharp TG. 1997. Determinants of longer duration of endotracheal intubation after adult cardiac operations. Ann Thorac Surg 63:1026-33.nChen A. 1998. Fast tracking in cardiac surgery: implications for practice. J Prog Cardiothorac Nurs 13:31-8.nCheng DC. 1998. Fast track cardiac surgery pathways: early extubation, process of care, and cost containment. Anesthesiology 88:1429-33.nCheng DC. 1998. Fast-track cardiac surgery: economic implications in postoperative care. J Cardiothorac Vasc Anesth 12:72-9.nCheng DC. 2005. Regional analgesia and ultra-fast-track cardiac anesthesia. Can J Anaesth 52:12-7.nCheng DC, Djaiani GN. 1999. Cardiac surgery; anesthesia techniques and postoperative sedation. Intensive Care Rounds, TMG Healthcare Communications 4168.nCheng DC, Karski J, Pentiston C, et al. 1996. Morbidity outcome of early versus conventional tracheal extubation following coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 112:755-64.nChong JL, Pillai R, Fisher A, Grebenik C, Sinclair M, Westaby S. 1992. Cardiac surgery: moving away from intensive care. Br Heart J 68:430-3.nDjaiani GN, Ali M, Heinrich L, et al. 2001. Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery. J Cardiothorac Vasc Anesth 15:152-7.nGersak B, Sostaric M, Kalisnik JM, Blumauer R. 2005. The preferable use of port access surgical technique for right and left atrial procedures. Heart Surg Forum 8:E354-63.nGlower DD, Landolfo KP, Clements F, et al. 1998. Mitral valve operation via Port Access versus median sternotomy. Eur J Cardiothorac Surg 14(suppl 1):S143-7.nHiggins TL. 1992. Pro: early extubation is preferable to late extubation in patients following coronary artery surgery. J Cardiothorac Vasc Anesth 6:488-93.nKehlet H, Wilmore DW. 2005. Fast-track surgery. Br J Surg 92:13-24.nMarianeschi SM, Seddio F, McElhinney DB, et al. 2000. Fast-track congenital heart operations: a less invasive technique and early extubation. Ann Thorac Surg 69:872-6.nOxelbark S, Bengtsson L, Eggersen M, Kopp J, Pedersen J, Sanchez R. 2001. Fast track as a routine for open heart surgery. Eur J Cardiothorac Surg 19:460-3.nPlümer H, Markewitz A, Marhohl K, Bernutz C, Weinhold C. 1998. Early extubation after cardiac surgery: a prospective clinical trial including patients at risk. Thorac Cardiovasc Surg 46:275-80.nRady MY, Ryan T. 1999. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med 27:340-7.nRoyse CF, Royse AG, Soeding PF. 1999. Routine immediate extubation after cardiac operation: a review of our first 100 patients. Ann Thorac Surg 68:1326-9.nSostaric M. 2005. Incisional administration of local anesthetic provides satisfactory analgesia following port access heart surgery. Heart Surg Forum 8:E406-8.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.nVincent J, Bihari DJ, Suter P, et al. 1995. Prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 274:639-44.nVintar N, Pozlep G, Rawal N, Godec M, Rakovec S. 2002. Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair. Can J Anaesth 49:481-6.nVircella LA, Dearani JA, Gaundry SR, Razzouk AJ, Brauer SD, Bailey LL. 2000. Ultra fast track in elective congenital cardiac surgery. Ann Thorac Surg 69:865-71.nWilmore DW. 2002. From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg 236:643-8.nWong DT, Cheng DC, Kustra R, et al. 1999. Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track anesthesia: a new cardiac risk score. Anesthesiology 91:936-44.n
