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Eur J Cardiothorac Surg 2004;25:116-122
© 2004 Elsevier Science NL

Fast-tracking revisited: routine cardiac surgical patients need minimal intensive care

Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK

Received 20 May 2003; received in revised form 4 September 2003; accepted 10 September 2003.

^* Corresponding author. Fax: +44-1-642-854613
e-mail: barradrum{at}hotmail.com

	Abstract

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
Objective: Following cardiac surgery, patients are transferred from the operating theatre to intensive care. This clinical environment has one nurse per patient and facilities for mechanical ventilation. Patients are kept in this setting until the following day. This practice has been challenged with early extubation of patients. At our institution we have established a fast-track policy including the following features: (1) patient selection; (2) operating list scheduling with fast-track patients first; (3) anaesthetic tailored to early extubation; (4) methodical procedure with warm cardiopulmonary bypass; (5) removal of the arterial line; (6) transfer from intensive care to a separate high dependency unit (‘step-down’) on the day of operation, where the ratio of nurse to patient is one to three and there are no ventilatory facilities and no invasive monitoring; or (7) to keep these patients on ICU but decrease the nurse to patient ratio. Method: The case notes of 572 patients who predominantly had myocardial revascularisation, undergoing this process from July 1996 to July 2000 at our institution were reviewed. Results: Mean EUROSCORE for the study group was 1.42. The 30-day mortality rate for the study group was 0.34%, mean intensive care time was 5 h 52 min, mean time to extubation was 3 h 10 min, mean readmission rate to intensive care was 0.34% and mean hospital stay from day of operation (inclusive) was 5.65 days. This process increased our throughput by 14.6% (compared to standard practices). Comment: This study demonstrates that transfer of appropriate patients to a high dependency area from intensive care following cardiac surgery is safe. It allows intensive care beds to be used by more than one patient each day and allows significant cost savings by reducing the nursing ratio per patient.

Key Words: ITU • Early extubation • High dependency

	1. Introduction

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
Newer guidelines for myocardial revascularisation [1] have generated greater demand for scarce resources. This, combined with higher risk patients presenting for cardiac surgery demands a closer evaluation of cardiac intensive care unit [CICU] bed usage. Current CICU practice is under challenge [2]. In many adult cardiac centres in the UK high-risk procedures in sicker patients reduce resource availability for routine coronary artery bypass graft (CABG) and valve replacement patients. Provision of post-operative intensive care is expensive and greater patient throughput is achievable without compromising patient outcome. Rather than deny the high-risk patient the requisite procedure and aftercare, thorough evaluation of resources required for the routine low-risk patient may improve overall practice and patient outcome.

Improvements in cardiopulmonary bypass (CPB) techniques, specifically advances in membrane oxygenation and blood sparing techniques have reduced the cerebral, pulmonary, renal and bleeding complications of cardiac surgery [3,4]. Normothermic CPB for standard low risk cardiac procedures is associated with minimal detriment and may benefit the patient compared with hypothermic perfusion [5,6]. Shorter CPB times, improved myocardial protection and anaesthetic methods allow extubation 2–3 h post-operatively, assuming haemodynamic stability [1,7]. Such patients can then be discharged to a ‘step-down’ or high dependency unit (HDU), allowing more than one low-risk patient per CICU bed per day.

A fast track process has been undertaken in our unit for several years, where a CICU bed is used for more than one cardiac surgical patient per day and patients are discharged from CICU on the day of surgery. Patient suitability for fast-tracking is determined by having a low probability for requirement of circulatory or respiratory support post-operatively and the absence of significant co-morbidity, corresponding with a low pre-operative risk stratification score (EUROSCORE). All elective patients discontinue anti-platelet medications 7–10 days preoperatively. Patients identified pre-operatively as suitable for the ‘fast-track’ process are placed first on each operating list.

The essential features of the process at our unit are:

• patient selection with least co-morbidity;
  
• organisation of the surgical list, with the lowest risk patient operated upon first;
  
• methodical surgery;
  
• an anaesthetic technique which provides excellent surgical conditions, early awakening and tracheal extubation, while maintaining stable haemodynamics and other organ function;
  
• intensive monitoring and care during early post-operative period; and
  
• step down to high dependency area with decreased of nurse/patient ratio.
  

A review of this process at our unit was performed. The results of the post-operative course of low risk elective and non-elective patients who underwent the ‘fast-track’ process at The James Cook University Hospital are described. This descriptive review aims to demonstrate that low risk routine coronary artery bypass and valve replacement patients do not require CITU care if haemodynamic and ventilatory support is not required.

	2. Methods and patients

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
The CICU database was used to identify patients who were fast-tracked at our unit, that is, were transferred from CICU to high dependency on the day of surgery, between the period of 1 July 1996 and 30 July 2000; 572 such patients were identified. The case notes and CICU charts were retrospectively studied and data were collected on the following aspects:

• patient demographics;
  
• pre-operative assessment;
  
• risk stratification scores (Euroscore);
  
• anaesthetic, surgical and CPB techniques;
  
• post-operative CICU and HDU care;
  
• length of CICU, HDU and hospital stay; and
  
• morbidity and mortality
  

2.1. Anaesthetic technique
The consultant anaesthetist assessed all patients for fitness for anaesthesia and surgery. Patients received oral lorazepam as night sedation and premedication, if appropriate. The anaesthetic technique and drugs were tailored towards early extubation.

Venous access with a large bore cannula and invasive blood pressure monitoring was established under local anaesthesia. Following pre-oxygenation, anaesthetic induction was achieved with 10–15 mcg/kg fentanyl, an induction dose of propofol or etomidate and 100–150 mcg/kg of pancuronium for muscle relaxation. Following tracheal intubation intermittent positive pressure ventilation (IPPV) was established. Central venous access was established with a multi-lumen catheter. A pulmonary artery catheter was floated or a sheath inserted for later use at the discretion of the anaesthetist. Intra-operative transoesophageal echocardiography (TOE) was used if indicated. Anaesthesia was maintained with air/oxygen and enflurane or isoflurane mixture and intravenous propofol infusion until bypass and then solely with propofol at 4–6 mg/kg per hour during and after CPB. Atracurium was used for additional muscle relaxation, if required.

Monitoring included lead II and V ECG, invasive blood pressure, central venous pressure, pulse oximetry, end-tidal CO₂ and anaesthetic vapour concentrations, nasopharyngeal temperature, urine output, ACT and intermittent blood gas analysis in all patients. Additional monitoring included TOE and pulmonary artery occlusion pressure, as appropriate. Alpha-stat method was used for arterial blood gas (ABG) management. Haemoglobin concentrations of greater than 7 g/dl on CPB and 8 g/dl on the day of operation were accepted.

Intra-operative haemodynamic management involved volume replacement or metaraminol boluses for hypotension and deepening of anaesthesia, GTN infusion or phentolamine boluses for hypertension.

2.2. Surgical techniques
The majority of cases were performed with cardiopulmonary bypass (CPB) with standard two-stage venous and ascending aortic cannulation, using a Cobe Optima (Cobe Inc., CO, USA) membrane oxygenator, maintaining non-pulsatile arterial flow rates of 2.2–2.6 l/m². All CABG cases were performed using intermittent aortic cross-clamping and fibrillation, maintaining patient core temperature at 37 °C. Valve replacements were performed with either antegrade blood or crystalloid cardioplegia and topical myocardial cooling. It is the practice of one of the surgeons to maintain normothermic systemic perfusion during standard solitary valve replacement. The remainder of valve replacement patients had core cooling to 32 °C.

2.3. Postoperative care
At the conclusion of surgery, all patients were returned to CICU, sedated and ventilated. Intensive care management involved one-to-one nursing, haemodynamic and respiratory monitoring, temperature and hourly urine output monitoring. Sedation was achieved with propofol infusion 1–2 mg/kg per hour and morphine infusion at 1–2 mg/h was added for analgesia. Further analgesia was achieved with nurse controlled morphine boluses and rectal paracetamol. Non-steroidal anti-inflammatory drugs (NSAID) were used in relatively younger patients with normal renal function and minimal post-operative bleeding. An air warming blanket was used to achieve normothermia. Postoperative chest X-rays were not routinely performed, unless clinically indicated. A consultant anaesthetist was physically present on CICU for advice and management at all times. Common reasons for consultation are as shown in Table 1.

The timing of discharge of ‘fast-track’ patients from CICU depends on the number of cases planned each day. As described earlier, the lowest risk patients are operated upon first aiming for uncomplicated recovery and prompt re-use of the CICU space.

	3. Results

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
A total of 572 patients were identified of whom 476 were male and 96 female. They had predominantly myocardial revascularisation. Mean age for the total group was 60.6 years and 309 patients (54%) were greater than 65 years of age. The study group represents 12.4% of a total of 4614 cardiac procedures performed in that time interval. Non-elective cases represent 15.6% of all procedures performed. ‘In-house urgent’ cases refer to patients admitted under cardiology services with unstable symptoms and maintained as in-patients until operated upon. Mean EUROSCORE [8] for the study group was 1.42, with a range of 0–8. Preoperative patient demographics are listed in Table 4. Trainees performed the procedures in 31.8% of all cases.

	4. Discussion

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
This audit of the ‘fast-track’ process at our unit demonstrates that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or major morbidity. This allows a greater throughput of patients with more efficient use of resources.

Increasingly a greater proportion of the adult cardiac patients presenting for both elective and emergency surgery are of higher risk status. Salvage procedures and advances in interventional cardiology have generated a divergence in the population requiring surgery between the younger low-risk patient, typically requiring revascularisation, and the older high risk patient requiring surgery to prolong life or possibly to allow hospital discharge. The necessity for prolonged CICU care for the latter group may be at the expense of the former group in many cardiac surgical practices. Preoperative selection of the low risk cases and expedition of their early post-operative care can help to perform the requisite number of routine CABG and valve replacement procedures, while not compromising patient outcome and still allow the increasingly high risk procedures.

Previous conventional intensive care management following cardiac surgery included prolonged elective ventilation. In most patients this, compounded by prolonged sedation, leads to a delay in the return of the patient to a normal ward and perhaps to a prolonged recovery. No benefit exists in prolonged ventilation following CABG in low-risk patients and such practice may be deleterious [9,10]. On the contrary, no benefit has been demonstrated from extubation in the operating room post CABG [11]. Recent series have supported a brief period of ventilation in CICU post-operatively [12].

Intensive care management remains expensive following cardiac surgery. ‘Fast-tracking’ cardiac surgical patients allows routine cardiac surgical patients to pass through the CICU, with minimal stay and provides the same bed for a further patient(s), who may or may not require a longer CICU admission period. As mentioned above, the 572 patients who underwent this process represents approximately 12.4% of the unit's cardiac surgical throughput over this time. Thus, ‘fast-tracking’ allowed approximately a further 14.2% throughput above that if this method was not exercised. As documented previously, an indeterminate number of our patients had the same post-op management as the fast-track patients remained on CICU on the night of surgery with a nurse/patient ratio of 1:2, when demand for the bed did not exist.

The essential factors of the fast-track process at our unit are: patient selection; appropriate anaesthetic agents; normothermic CPB; and a designated cardiac intensive care complemented by the presence of a specialist cardiac high dependency unit (HDU). Methodical surgery is vital whilst maintaining good opportunity for training. A conscious extubated haemodynamically stable cardiac surgical patient is thus transferred early postoperatively to the HDU, where the nurse to patient ratio is one to three, without the need for mechanical ventilation or invasive arterial pressure monitoring. The patient undergoing the ‘fast-track’ process at our unit does not by design of the process require an arterial line on transfer to the HDU. This is an important fact in allowing for a reduction in the nurse to patient ratio from 1:1 to 1:3.

A previously common anaesthetic technique used incorporates high dose opioids, which minimise haemodynamic changes at induction, endotracheal intubation and sternotomy. This method requires an obligatory period of mechanical ventilation in intensive care. This method has been latterly challenged by the use of propofol for anaesthesia during cardiac surgery [13]. The major benefit of propofol, compared to high dose opioids, is the shorter recovery time leading to a reduction in time to extubation. Propofol has no adverse effects in patients with poor LV function or unstable angina. Patients undergoing cardiac surgery with a propofol based anaesthetic sustain less myocardial ischaemia compared to patients undergoing other anaesthetic regimens [14].

Proper selection of suitable low-risk patients for this process is paramount and these patients need to have their procedures performed first on each operating list. Other authors emphasise the importance of patient selection [12] and every case is not suitable for fast-tracking. Previous authors have demonstrated that the duration of CICU stay can be predicted [15]. This study does not aim to demonstrate a correlation between short ischaemic times, short cardiopulmonary bypass times and improved patient outcomes. However, we feel that these factors, in combination with maintaining core temperature at 37 °C during bypass, may expedite discharge from CICU in these patients. Other groups have attempted to address these questions, demonstrating that normothermia is not associated with adverse consequences in routine patients [5].

The safety of discharging CABG patients from intensive care on the day of surgery has been described [12]. Fast-tracking in such units has not been associated with increased readmission rates to CITU and has demonstrated reduced hospital stay [12]. Similarly, this study did not demonstrate increased morbidity with fast-tracking. Other units have advocated postoperative management where the routine low-risk cardiac surgical patient is allowed to recover and be extubated and monitored in a designated cardiac surgical recovery area. This has been described for a similar study group to this study [16], with excellent results, whereby patients are only admitted to an intensive care unit on the basis of very poor left ventricular function, requirement for an IABP, preoperative multiorgan system failure or poor respiratory function. We believe that the ‘fast-track’ process that we describe has distinct advantages: first that the recovery of these low risk CABG and valve patients is monitored by a senior intensivist dedicated to the CICU, who also oversees the management of other higher risk patients. Second, if a routine patient sustains a ‘near-miss’, they are already in an ICU setting with full cardiopulmonary support available. Finally, this system is not dependant on the availability of beds from a ‘general’ intensive care, which is impractical in modern cardiac surgical practices. The ‘fast-track’ process as described at our unit allows the use of a single ITU bed and ITU nurse for two patients in at least 12.4% of our total practice. In 71 patients of the study group (12.4%) a third patient and in 17 patients (3%), a fourth patient used the same ITU bed.

Fifty-four percent of our study group were greater than 65 years old. While our fast-track procedure differed from that of other authors describing early extubation in elderly cardiac surgical patients, age singularly is not a contraindication to fast-tracking [17,18].

Our fast-track process refers specifically to the early post-operative period, with early extubation and discharge from CITU. The mean time to discharge is 5.65 days, which is comparable to other fast-track systems [12,16]. We acknowledge that the fast-track process is not a precise definition but a modification of the methods already present in individual cardiac surgical units. This includes anaesthetic, surgical, intensive care and nursing practices. The fast-track process described in this article may not suit every cardiac unit.

In conclusion, this study demonstrates that ‘fast-tracking’ of selected routine low-risk cardiac surgical patients, as described, produces excellent patient outcome, mortality and morbidity at least comparable to other fast-track processes post cardiac surgery, while allowing a greater throughput of patients through the intensive care beds, reducing nursing requirements and more efficient use of stretched resources. Previous traditional attitudes to the post-operative management of routine cardiac surgical patients may require change.

	5. Limitations of this study

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion 5. Limitations of this... References

 
This is a retrospective descriptive study. While randomising patients of equal low risk stratification between ‘fast-track’ and the routine CITU stay may be the ideal study model, we feel this is unwarranted, considering the low mortality/morbidity described here. We were unable to accurately calculate the actual number of patients selected preoperatively that were successfully ‘fast-tracked’.

	Acknowledgments

 
We acknowledge the contribution of Mr S. Hunter, Mr J. Wallis, Mr A. Owens, Mr G. Morritt, Dr R. Miekle, Dr N. Stratford, Dr A. Mellor, Dr J. Parke, Dr N. Barnham and Dr A. Symon.

	References

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