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Fast-Track/Off Pump/Prediction/Outcome

Re-admission and mortality rate after a fast-track recovery protocol in off-pump coronary artery bypass surgery patients: 079

Celkan, M. A.; Kazaz, H.; Ustunsoy, H.; Daglar, B.; Kocoglu, H.*

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 23

Introduction: Development of off-pump cardiac surgery and fast-track recovery has contributed to a significant reduction in postoperative intensive care unit and hospital length of stay after cardiac surgery. The aim of this study was to identify the hospital mortality and readmission rate after offpump coronary revascularization and a fast-track recovery protocol.

Method: After approval of the ethical committee, 80 consecutive patients undergoing off-pump coronary artery bypass surgery were included in the study, and followed a fast track protocol defined as successful extubation within 6 hours postoperatively, length of stay in intensive care unit less than 24 hours, and hospital discharge within 5 days [1,2]. Patients were extubated when they fulfilled the extubation criteria (responsive and cooperative, negative inspiratory force > −20 cm H2O, vital capacity > 10 mLkg−1, arterial oxygen tension > 80 mmHg, FiO2 < 0.50, pH > 7.30, chest tube drainage < 100mLh−1 × 2h). Hospital readmission and the reason for readmission were recorded together with the mortality rate during the following 30 days. Those patients who had not met the protocol were excluded from the study. Patients were premedicated with midazolam (0.1 mgkg−1, im.). Anaesthesia was induced with fentanyl (2 μg kg−1) and propofol (1-2 mgkg−1), and maintained with fentanyl (0.1 μg kg−1 min−1, iv.) and isoflurane 0.6-1.0% with 100% oxygen. Neuromuscular blockade was achieved by vecuronium bromide (0.1 mgkg−1, iv.) and maintained by bolus administration (0.03 mgkg−1) at 30 min. intervals. Statistical analysis was performed using SPSS statistical software programme with chi-squared test and Fischer's exact test for univariate and multivariate logistic regression analysis.

Results: Seventy patients (87.5%) were extubated in the postoperative first six hours. Mean mechanical ventilation time was 4.5 ± 2.4 hours. Three patients died before discharge from the hospital giving a hospital mortality rate of 3.85%. The causes of hospital death were stroke and sepsis. Mean hospital length of stay was 4.2 ± 1.1 days. Thirteen patients were not discharged within five postoperative days. Postoperative blood transfusion was found to be significantly associated with prolonged hospital stay. During the 30-day observation period from the day of discharge, 7 patients (10%) were readmitted to the hospital. The reasons for readmission were sternum infections and dehiscence (3 patients), pleural effusions and pneumonia (2 patients), chest pain (1 patient), and subcutaneous emphysema (1 patient). One of the readmitted patients died on postoperative 45th day because of mediastinitis and sepsis.

Discussion: The mortality and readmission rates in this observational study were found to be similar to the previously reported findings [2]. We conclude that off-pump CABG surgery with this fast track protocol can be performed with similar outcome as reported earlier.

References:

1 Cheng DHC. Fast track cardiac surgery pathways. Early extubation, process of care and cost containment. Anaesthesiology 1998; 88: 1429-1433.
2 Myles PS, Daly DJ, Djaiani G, et al. A systematic review of the safety and effectiveness of fast-track cardiac anesthesia. Anesthesiology 2003; 99: 982-987.
© 2004 European Society of Anaesthesiology