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Eur J Cardiothorac Surg 2001;19:460-463
© 2001 Elsevier Science NL

Fast track as a routine for open heart surgery

Heart Center Varde, 6800 Varde, Denmark

Received 4 October 2000; received in revised form 26 January 2001; accepted 5 February 2001.

Corresponding author. Tel.: +45-76-950100; fax: +45-75-222277
e-mail: sten{at}bypass.dk

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results Appendix A. Conference... References

 
Objective: Evaluation of thoracic epidural analgesia (TEA), normothermic cardiopulmonary bypass (CPB) and normothermic blood cardioplegia as a routine procedure for fast track open heart surgery. Methods: Consecutive patients (n=250, age 36–81 years, mean 63, M/F, ratio=4) were subjected to the combination of general anaesthesia using ultra-short acting opiates, TEA, normothermic CBP, normothermic whole blood cardioplegia. Operative procedures included coronary artery bypass grafting (CABG), valve replacement, combined CABG and valves, aortic aneurysm and Maze III. LVEF ranged 20–76%. Eighty percent were in Tuman score 0–5 and 20% in score >5. Results: All patients were extubated within 10 min after skin closure. There was one myocardial infarction. Four percent were shortly treated with cathecholamines. Postoperative atrial fibrillation was noticed in 9.6%. Four transient cerebral ischemic events were encountered. No neurological disturbance related to the use of TEA was seen. Seven patients were reoperated because of bleeding. Blood transfusion was given to 6.4% of the patients. Mortality was 0.8%. Conclusions: The combined methods provides a way for routine immediate postoperative extubation, with low morbidity and short hospital stay.

Key Words: Fast track surgery • Thoracic epidural catheter • Normothermia • Blood cardioplegia

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results Appendix A. Conference... References

 
Procedures to minimize surgical, anesthesiological and cardiopulmonary bypass trauma during open heart surgery are continuously developed in order to reduce the limitations for surgical treatment of heart disease. Minimizing trauma reduces morbidity and thereby shortens length of hospital stay.

We here report the routine application of the combination of described methods, though previously described separately, i.e. thoracic epidural analgesia (TEA) combined with i.v. ultrashort acting opiates for anaesthesia, normothermic cardiopulmonary bypass (CPB), normothermic whole blood cardioplegia.

The aim of the protocol was immediate extubation in the operating room and fast mobilization of the patient.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results Appendix A. Conference... References

 
2.1. Patients and procedures
From August 1st, 1999 to July 31st 2000, 250 unselected consecutive adult patients were operated. Patient population is reported in Table 1. Mean age was 63 (36–81) years, M/F, ratio 4. Eighty percent were in Tuman score 0–5 and the rest >5 [1]. Left ventricular ejection fraction ranged 20–76%. Aortic occlusion time ranged 11–123 min (mean 33) and CPB time 26–211 min (mean 65). The protocol has been applied in CABG, aortic valve replacement, mitral valve repair/replacement, combined CABG and valve operation, redos, left ventricular aneurysm resections, ascending aortic aneurysm resections and maze III procedures. The performed operations are listed Table 2.

The epidural catheter was checked as above before induction of anaesthesia. Before start of general anaesthesia, a bolus of 8–10 ml bupivacain (Marcain^®) /sufentanil (Sufenta^®) was given epidurally (4.5 mg/ml bupivacain and 5 µg/ml sufentanil) and assured sufficient for anaesthesia of thorax.

General anaesthesia was started and maintained by continuous infusion of propofol (Diprivan^®) and remifentanyl (Ultiva^®). For muscle relaxation 50 mg of atracurium (Tracium^®) was administered, and no further muscle relaxantia was given.

The patients were monitored with a 5-lead ECG, invasive arterial pressure, oesophageal ultrasound, Swan–Ganz catheter, pulse oxymetry and central temperature.

Hemodynamic profiles were obtained after induction of anaesthesia, before wound closure and in the intensive care unit.

For postoperative pain relief, the epidural catheter administering bupivacain/sufentanil together with patient controlled analgesia (PCA), was used. Only paracetamol (Pamol^®) orally was supplemented.

2.3. Cardiopulmonary bypass protocol
An open CPB system with arterial filter (40 µ) was used. Heparinization of the patient was performed with 3 mg/kg body weight to an activated clotting time (ACT) more than 400 s. Cardiopulmonary bypass was performed with active warming (arterial temp. 37.5°C) and the core temperature was kept at 36.5°C. Blood flow was maintained at 2.8 l min^-1 BSA^-1 and not permitted to be lower than 2.4 min^-1 BSA^-1. Perfusion pressure was kept within the range of 40–70 mmHg. Low blood pressure was treated with metaoxedrin (0.1 mg/ml) in repeated single doses.

2.4. Cardioplegic protocol
Intermittent normothermic (37°C) whole blood cardioplegia from the arterial line of the CPB unit, supplemented with potassium, magnesium and adenosine was given ante- and/or retrograde. To arrest the heart, 1000 ml cardioplegia at a potassium concentration of 20 mmol/l was administered. For maintenance of diastolic arrest, 300 ml cardioplegia at a potassium concentration of 8–10 mmol/l was given at least every 5–10th min. For certain procedures cardioplegia was given almost continuously, i.e. valve replacement, aortic aneurysm resection, maze procedure.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results Appendix A. Conference... References

 
The postoperative course are summarized in Table 3. All patients were extubated in the OR from just before, up to 10 min after skin closure. No patient had to be reintubated due to respiratory or cardiac failure. One myocardial infarction was encountered as measured by CKMB release. Eleven (4.4%) patients received cathecholamines in the early postoperative period (<24 h) due to cardiac and/or renal insufficiency. The incidence of early reoperation caused by bleeding or tamponade was 2.8%. One patient suffered from permanent neurological defect and four (1.6%) from transient cerebral ischemia. Postoperative atrial fibrillation was in 9.6% of the patients. Blood transfusion was given in 6.4% of the patients.

No complications (neurological, infection) from the thoracic epidural analgesia procedure was seen. Mean length of hospital stay was 5.4 days (range 4–43 days). Eighty-eight percent of the patients were discharged directly to their homes.

4. Discussion
This paper describes the combination of four methods applied in open heart surgery, previously only been described separately, i.e. TEA, ultrashort acting opiates, normothermic CPB and normothermic whole blood cardioplegia. To our knowledge has the combination of the methods not been described or applied clinically earlier. The aim using the combined methods was to achieve extubation in immediate conjunction with skin closure in all kinds of adult cardiac surgery.

In this paper, the method was applied in 250 unselected, consecutive adult patients of many kinds of cardiac operations or preoperative risk factors, and all patients could be extubated in the operation room. As a curiosity, a significant number of patients were in fact extubated while suturing the skin of the patient, enabling conversation between the anaesthetist and the patient and many patients called their relatives by phone within half an hour postoperatively.

Earlier studies has described the use of thoracic epidural anaesthesia for cardiac surgery and reported a decrease in the period of postoperative ventilator treatment [2]. In a recent study of 100 patients receiving TEA for CABG, the median time to extubation was 12 h, with 21% of the patients extubated within 1 h postoperatively [3].

It has been advocated that a fast track protocol should be applied to selected patients, excluding patients with high risk due to poor cardiac function and patients with preoperative respiratory dysfunction [4]. Though our material is limited in number, it does challenge this statement, as our patients were unselected. In patients with poor left ventricular performance (EF<35%) and a high preoperative risk score (Tuman>7 points), all patients could be extubated immediately after the operation. Hence, an interesting hypothesis to put forward from these data is, that high-risk patients may benefit from the use of TEA and immediate postoperative extubation.

The combination of an epidural catheter and full anticoagulation during cardiopulmonary bypass is controversial, due to the risk of epidural hematoma. We have used TEA for more than 1500 patients, without any spinal complications [5]. Several other studies, using TEA for cardiac surgery support this observation [6].

Using normothermic CPB and normothermic blood (hematocrit 20–25) from the CPB unit for cardioplegia, you get closer to the physiological circulatory situation of the whole patient and the heart than using hypothermia and various crystalloid solutions. The risk of neurological injury due to known or unknown arteriosclerotic lesions of the cerebral circulation cannot be neglected using normothermic perfusion. In our series we applied a slightly increased perfusion pressure in this risk group and the incidence of neurological complications were low.

Normothermic blood for cardioplegia eliminates the hypothermic and osmotic trauma to the endothelium of the coronary circulation, likely to improve the preservation of the physiological blood–endothelial interaction, especially important in the reperfusion phase. The threat of increased myocyte damage in the normothermic arrested heart did not show any significance with only one clinically obvious infarction. In fact the postoperative enzyme levels most often were within normal range.

The number of patients that received blood transfusion was 6%. In the STS cardiac database analysis 1995–1996 blood products was used in 32% of the CABG patients in the lowest risk group. London et al. [7] reported an overall use of blood units of 31.9% in 304 patients, where a fast track protocol was used for CABG.

The use of TEA plays a central role, as it facilitates complete postoperative pain relief with safe and early extubation. Intrathoracic pressure, pulmonary ciliar function and mucous transport are normalized, and the patients can breathe deeply and cough without pain, all of which may decrease the incidence of atelectasis, hypoxia and pulmonary infection [8].

One drawback of the use of postoperative epidural pain treatment may be that the reduced pain in the chest would make the patients less reluctant to avoid physical traction stress to the sternum, hence increasing the risk of sternal dehiscence. However, the rate of reoperation for sternal dehiscence was only 0.4% in this material, but it is certainly important to make a good surgical closure of the chest.

It was our clinical impression that the excellent postoperative pain treatment was important to achieve early mobilisation. These patients were much easier to handle, with a pronounced reduction of the working load of the nursing staff, compared to patients with traditional postoperative pain treatment.

If it is possible with early mobilisation of the patients, it means generally low morbidity. This will result in a short hospital stay and thus lowering the costs [9]. Especially after long and complicated surgery, as maze-operation, combined procedures and aortic root reconstruction, it was obvious, that these patients were able to walk without any help to the dining room on the first postoperative day.

Early mobilization and quick restoration of normal physiological function after open-heart surgery is possible, when TEA is used as the main analgesic component. The morbidity and mortality data from this material indicate, that the procedure is safe. Furthermore, the data suggest, that patients with poor cardiac performance and/or high preoperative risk, benefit from this technique.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results Appendix A. Conference... References

 
Dr A. Chaikhouni (Aleppo, Syria): Would you kindly tell me to what level do you advance your epidural catheter and what is the material that you use and for how long do you leave it postoperatively?

Dr Oxelbark: We put in the catheter at the thoracic space two or three or three to four, so that will cover down to the lower abdomen, and the catheter remains in place four days usually.

Dr H.C. Alhan (Istanbul, Turkey): Is the data that you presented the same with the one published in the abstract, because all the figures are different and cross-clamp times, cardiopulmonary bypass times, bleeding, etc. What is the reason for this disparity?

Dr Oxelbark: That's right. We wrote this abstract in March and the collection of patients was finished in June. So that makes the difference. And we had a relatively big part of the patients operated into June.

Dr A. Arbulu (Detroit, MI, USA): Of course it is important to categorize the patient as to the state of nutrition and the pulmonary function. We tried to work on the fast tracking, and we find a lot of difficulties with our patients. The average age of our patients is 74 years and a very poor state of nutrition. So therefore my question is if you categorize the patients in relation to that.

The medical profession is under a lot of pressure in the States as well as here, in Europe, as to the shortening of patients’ stay, however, I think that as far as I know, for the first time there has been a publication from the University of Michigan of almost 13 000 patients that stay in the hospital four days or longer published in the August issue of the Journal of the American College of Surgeons. Actually patients discharged beyond four days only exceed their cost of hospitalization by a factor of 2.4%. The most expensive part was actually the initial four days of hospitalization.

Dr W. Harringer (Hannover, Germany): One of the problems with fast track surgery is a certain reintubation rate, ranging around 10–20% in some of the published series. Could you comment on this? Did you have to reintubate any patients? And the second question would be: at what time point do you insert your thoracic epidural catheter? Is it the evening before, or is it right immediately before you start surgery? What is your policy on that?

Dr Oxelbark: Most of the patients were elective, and then you put in the day before, or the evening before, actually, operation. Some patients are more or less acute, and then you put in a couple of hours before operation. That also worked good.

Certainly we had a couple of reintubations. I am not quite sure, but there were very few reintubations, very few, and the time they stayed on the ventilator was also very short.

Dr F. Wellens (Aalst, Belgium): These excellent results are not so much related to the fast track surgery but, in my opinion, to patient selection, and to the extra short cardiopulmonary bypass time, with the series you presented, this kind of operation, even the most skilful surgeon in my group cannot perform this operation with a mean of 33 min cross-clamp time and 65 min extracorporeal bypass time. I think this is the main reason for the excellent results in the early post-op.

Dr Oxelbark: Well, you know, of course everything plays a role, what you are doing, everything plays a role, but I have experience before when I did exactly the same operation and now with this fast track, and my opinion is that this model of fast track is definitely a step forward.

Dr J. Tatoulis (Melbourne, Australia): I wonder if you could please comment on the requirement for noradrenaline or other pressor support. We use this technique (thoracic epidural), in about a third of our patients and find that they become hypotensive with high cardiac output, low systemic vascular resistance, and we often have to support them with noradrenaline. Could you comment on your experience with that?

Dr Oxelbark: That's interesting. I myself am astonished that the patients are not very much low pressure postoperative in spite they have this thoracic catheter, but I think it depends. The patients are really awake. They are not depressed by a lot of narcotics. So the patient, he is reacting more or less normal. We even take out the urine catheter very early post-op despite the thoracic catheter. So more or less the physiological regulations take care about the blood pressure. I would say they have a tendency to have high blood pressure. Every day we are going and taking around and telling the nurses, lower the blood pressure, please, because otherwise we are anxious that they are going to bleed.

Mr A. Youhana (Swansea, UK): Two questions related to your epidural. Do you use your epidural purely for postoperative analgesia or is it used for intraoperative anaesthesia? And the second one is, if you have a failure of an epidural the day before the surgery, do you tend to cancel the case due to the possibility of bleeding with heparinisation and have you had any complications with epidural?

Dr Oxelbark: We didn't have any complications with epidurals. And of course we used the pain relief also during operation, so we don't give them that much narcotics.

And the other question was?

Dr Youhana: And the second question was, do you cancel your case if there is failure of the epidural?

Dr Oxelbark: No. We just take it out and put in another one, and that will work.

Mr. R. Ascione (Bristol, UK): Just one question, and this is regarding your anticoagulation protocol. Was this just a standard one or different, as there is a small risk of bleeding related to this procedure?

Dr Oxelbark: If a patient is coming fully anticoagulated, we try to put him over on low molecular heparin and wait until the INR is down a bit.

Dr E. Wolner (Vienna, Austria): If you will allow me one final comment, may I suggest the application of the Euroscore or the Parsonnet score the next time you present your results. I believe this would be of great interest to the readers.

	References

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6. Odoom J.A., Sih I.L. epidural analgesia and anticoagulant therapy. Experience with one thousand cases of continuous epidurals. Anaesthesia 1983;38:254-259.[Medline]
7. London M.J., Shroyer A.L., Coll J.R., MaWhinney S., Fyllerton D.A., Hammermeister K.E., Grover F.L. Early extubation following cardiac surgery in a veterans population. Anaesthesiology 1998;88(6):1447-1458.[Medline]
8. Stenseth R., Bjella L., Berg E.M., Christensen O., Levang O.W., Gisvold S.E. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardio-thorac Surg 1996;10:859-865.[Abstract]
9. Cheng D.C.H., Karski J., Peniston C., Raveendran G., Asokumar B., Caroll J., David T., Sandler A. Early Tracheal Ectubation after coronary artery bypass graft surgery. Reduces costs and improves ressource use. Anaesthesiology 1996;85:1300-1310.[Medline]

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