623 Ultra fast track cardiac surgery and anaesthesia: A collaborative team approach

Abstract

The advantages of minimally invasive coronary artery bypass grafting (CABG) surgery over conventional CABG include shorter recovery time, overall reduction in morbidity, blood transfusion, greater patient satisfaction, shorter hospital stay, and earlier return to work. In order to explore the opportunities within our practice to improve patient care while at the same time protecting our patients from harm and reducing costs to our financially challenged hospitals, we identified an opportunity to explore the option of bypassing the intensive care unit (ICU) in a highly selected group of patients undergoing minimally invasive coronary artery bypass surgery. This was accomplished through an extensive collaboration between nurses, administrators and physicians alike. A collaborative pathway was constructed for selection of suitable patients by the surgeon and anaesthesiologists based on the grounds of compatible coronary anatomy for minimally invasive coronary artery revascularization. Secondary factors included minimal systemic co-morbidity. A total of 14 patients underwent successful fast track cardiac surgery. There were 12 males and 2 females. They all received preoperative spinal injection of 15 mg of bupivacaine and 3 to 5 mcg/kg of preservative free morphine prior to their general anaesthesia. Using single lung ventilation they underwent Robotic-assisted CABG. Immediately after the revascularization they underwent cardiac catheterization to confirm patency of their graft and simultaneous percutaneous coronary intervention in 2 patients in the hybrid operating suite. Simultaneously, their anaesthetic and neuromuscular blockade was reversed achieving spontaneous respiration. Following clinical confirmation of return of spontaneous respiration, wakefulness and protective airway reflexes, the endotracheal tube was removed, and the patients were transferred to the post anaesthetic care unit (PACU). All patients were monitored in the PACU for 4 to 6 hours before being transferred to the postoperative ward. One patient had to return to the operating room for increase bleeding after 3 hours. He underwent uncomplicated exploration for chest wall bleeding. All patients had patent grafts, no post-operative complications and were extremely satisfied on discharge. Average length of stay in hospital was 3.1 ± 0.78 days. We believe Ultra fast track cardiac surgery is a safe and efficient way to conduct cardiac surgery in a highly selected group of patients. The importance of collaboration and a team based approach cannot be emphasized enough. We anticipate expanding this program within our own institution and look forward to evaluating the cost effectiveness of avoiding the ICU.