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Fast-Track/Off Pump/Prediction/Outcome

Alfentanil-based general anaesthesia for early extubation after valve surgery: 072

Vanek, T.; Straka, Z.; Brucek, P.; Jares, M.; Votava, J.

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 22
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Introduction: New approaches are being continuously developed in cardiac anaesthesia, with early extubation and rapid mobilization of the patient being two of the most important and popular topics. Many authors focussed on offpump coronary surgery [1,2]. Here we report a review of our first 100 patients who underwent heart valve/aorta or combined procedures with alfentanilbased fast-track general anaesthesia without the use of an epidural catheter.

Method: One hundred unselected patients undergoing elective valve surgery (15 low risk patients with additive EuroSCORE 0-2, 39 medium risk patients with EuroSCORE 3-5, 46 high risk patients with EuroSCORE 6 plus) of a consecutive series, were anaesthetized by general anaesthesia based on alfentanil, midazolam, isoflurane and atracurium.

Criteria for extubation were:

Normotension, heart rate <120/min., no signs of LCO

PaO2 > 80 mmHg and PaCO2 < 45 mmHg at FiO2 0.5

Spontaneous smooth ventilation, patient can lift the head

Full contact with the patient responsive to simple command

Bleeding <100 mL within last 30 mins.

Results: The average total dose of alfentanil per procedure was 10.5 = 3.4mg, i.e. 134 = 36 μg kg−1. Eighty-four (84%) patients (i.e. 14 [93.3%] low risk, 33 [84.6%] medium risk, 37 [80.4%] high risk patients) were extubated within 30 minutes from the end of surgery. Fifty-eight out of these patients were extubated in the operating room less than 10 minutes after skin closure and 26 were extubated in the intensive care unit (ICU). One patient was re-intubated and ventilated for a further 24 hours because of transient cerebral ischaemia. Five patients were re-intubated because of the need for early surgical re-exploration (bleeding or cardiac tamponade). Two high risk patients died of heart failure without any attempt at extubation. Ten patients (of those extubated within 30 minutes) were successfully discharged from ICU on day 0 (4 low risk, 4 medium risk, 2 high risk patients).

Discussion: Alfentanil-based general anaesthesia seems to be readily reproducible and can be recommended for on-pump procedures as well as for high risk patients. Fast-track with early extubation of patients is the first step on the way to reducing ICU length of stay and achieving savings in cardiac surgery [3]. Based on our experience with 100 patients, the method is promising in terms of safe ICU discharge on the day of surgery for selected cases.

References:

1 Djaiani GN, Ali M, Heinrich L, et al. Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery. J Cardiothorac Vasc Anesth 2001; 15: 152-157.
2 Straka Z, Brucek P, Vanek T, et al. Routine immediate extubation for off-pump coronary bypass surgery without thoracic epidural analgesia. Ann Thorac Surg 2002; 74: 1544-1547.
3 Cheng DC, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. Anesthesiology 1996; 85: 1300-1310.
© 2004 European Society of Anaesthesiology