Early Activation of Patients after Surgery for Coronary Heart Disease under Extracorporeal Circulation

Abstract

Objective: to analyze the safety and clinical efficiency of early activation of patients operated on for coronary heart disease under extracorporeal circulation. Subjects and methods. The data available in the case histories of 673 patients aged 29—76 years, operated on in 1995, 2004, and 2006, were analyzed. The study excluded patients with severe intraoperative complications (acute myocardial infarction, a need for extracorporeal circulation, and surgical bleeding). Early activation was made on an operating table if there were no contraindications. Some sections of the study were performed in the matched patient groups. Results. With early activation, the dosages of fentanyl were reduced by 2.5-3 times as compared with the 1995 data; the use of ketamine and diazepam was stopped. Instead of the latter, the currently available inhalational agents are coming into use: midazolam has been introduced and the rate of propofol use has increased. The higher activation rate required the use of flumazenil, naloxone, and proserin. The goal-oriented study of central hemodynamics with emphasis on early activation has indicated that lower dosages of fentanyl have no negative impact on cardiac pump function or myocardial oxygen balance. When the trachea was extubated on the operating table, there was appropriate central hemodynamic stabilization. It was found that the incidence of postoperative myocardial infarctions did not depend on the rate of activation. The frequency of cardiovascular complications was 38.8±5.9% and 22.9±5.0% in the prolonged artificial ventilation (AV) and early activation groups, respectively (p<0.05); that of pulmonary complications was 16.4±4.5% and 5.7±2.8%, respectively (p<0.05). Early activation halved the length of stay at an intensive care unit (p<0.05) and reduced postoperative hospitalization at surgery units by 5 days (p< 0.05). Introduction of early activation caused a decrease in the duration of postoperative AV in the patients, inactivated in the operating-room, from 16±1 hours (in 1995) to 7±1.2 hours (in 2006). Conclusion. The results of the goal-oriented studies, as well as the analysis of an array of clinical data suggest that early activation after myocardial revascularization under extracorporeal circulation is a safe and clinically effective methodological approach to anesthetic and intensive care management in cardiac surgical patients with coronary heart disease. Key words: early activation, myocardial revascularization, operations under extracorporeal circulation, tracheal extubation in the operating-room.