Fast-Tracking in Cardiac Surgery—Is It the Patient or the Protocol?

Abstract

Early extubation after uncomplicated cardiac surgery using a fast-track (FT) protocol has been advocated as a means of reducing postoperative ventilation time, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The overall objective is to improve throughput, without increasing morbidity or complications. In a recent Cochrane systematic review, Wong et al.1Wong W.T. Lai V.K. Chee Y.E. et al.Fast-track cardiac care for adult cardiac surgical patients.Cochrane Database Syst Rev. 2016; 9CD003587PubMed Google Scholar demonstrated that there was no significant difference in mortality rate or major complications between FT protocols and conventional management, and FT was considered safe for patients whose perioperative risk was deemed to be low or moderate. The best practices have led to the development of guidelines for enhanced recovery after cardiac surgery.2Gregory A.J. Grant M.C. Manning M.W. et al.Enhanced recovery after cardiac surgery (ERAS Cardiac) recommendations: An important first step—but there is much work to be done.J Cardiothorac Vasc Anesth. 2020; 34: 39-47Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar,3Engelman D.T. Ben Ali W. Williams J.B. et al.Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations.JAMA Surg. 2019; 154: 755-766Crossref PubMed Scopus (225) Google Scholar Bhavsar and Jakobsen present a large retrospective database study of 31,800 patients from 2000 to 2017.4Bhavsar R. Jakobsen C.J. Are fast-track protocols a myth and the decrease in resource utilisation simple demographics?.J Cardiothorac Vasc Anesth. 2020; 34: 1476-1484Abstract Full Text Full Text PDF Scopus (2) Google Scholar This involved 3 cardiac surgical centers without a specific FT protocol. All patients were managed in the ICU postoperatively, rather than a postanesthesia care unit (PACU) or intermediate care area. Over this time frame, the median patient age increased by 2 years, from 65 to 67 years; however, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) comorbidity progressively reduced. The key finding was an association among comorbidity and prolonged postoperative ventilation time, ICU LOS, and hospital LOS. Patients with lower comorbidity scores achieved earlier times to extubation, as well as shorter ICU and hospital LOS, despite no specific FT protocol. The authors concluded that outcome was related primarily to comorbidity, and that a specific FT protocol would be unlikely to improve results further in their setting. Several factors warrant further discussion to interpret the generalizability of these results. Firstly, the population studied was a particularly healthy one, with lower comorbidity scores despite increasing age. Interestingly, the authors demonstrated a reduction in requirements for inotropic support and increasing vasopressor support in the study population over time. It is not clear whether this was an intentional change in practice, in keeping with the recent literature demonstrating no survival advantage of epinephrine over norepinephrine in cardiogenic shock,5Levy B. Clere-Jehl R. Legras A. et al.Epinephrine versus norepinephrine for cardiogenic shock after acute myocardial infarction.J Am Coll Cardiol. 2018; 72: 173-182Crossref PubMed Scopus (127) Google Scholar, 6Squara P. Hollenberg S. Payen D. Reconsidering vasopressors for cardiogenic shock: Everything should be made as simple as possible, but not simpler.Chest. 2019; 156: 392-401Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 7Schumann J. Henrich E.C. Strobl H. et al.Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome.Cochrane Database Syst Rev. 2018; 1CD009669PubMed Google Scholar or whether this reflected an improvement in left ventricular ejection fraction in the study population over time. The demographic described in this study is significantly different from other parts of the world that may face an increasingly elderly patient population with increased number and severity of comorbidities. Pierri et al. reviewed a database of 10,000 patients over 9 years in a Mediterranean region, and identified an increasingly elderly patient population with greater comorbidities such as hypertension and obesity as well as adverse hemodynamic profiles, including reduced left ventricular ejection fraction, hemodynamic instability, or shock.8Pierri M.D. Capestro F. Zingaro C. et al.The changing face of cardiac surgery patients: An insight into a Mediterranean region.Eur J Cardiothorac Surg. 2010; 38: 407-413Crossref PubMed Scopus (33) Google Scholar Ueshima et al. reviewed the prevalence of cardiovascular disease risk factors in an Asian population compared with published data from Western populations, and found a higher incidence of stroke, diabetes, hypertension, and hyperlipidemia.9Ueshima H. Sekikawa A. Miura K. et al.Cardiovascular disease and risk factors in Asia: A selected review.Circulation. 2008; 118: 2702-2709Crossref PubMed Scopus (469) Google Scholar Secondly, the institutions adopted an ICU-centric model, whereby all postoperative patients were looked after in an ICU after any type of cardiac surgery.4Bhavsar R. Jakobsen C.J. Are fast-track protocols a myth and the decrease in resource utilisation simple demographics?.J Cardiothorac Vasc Anesth. 2020; 34: 1476-1484Abstract Full Text Full Text PDF Scopus (2) Google Scholar Other centers may use a PACU-centric model, whereby suitable patients are preselected to bypass the ICU altogether. In these centers, it may be prudent to identify patients suitable for an FT protocol, compared with patients who would be more likely to have higher postoperative ventilatory and inotropic support requirements, as there may be significant cost savings associated with this.10Taware M. Sonkusale M. Deshpande R. Ultra-fast-tracking in cardiac anesthesia “Our Experience” in a rural setup.J Datta Meghe Inst Med Sci Univ. 2017; 12: 110-114Crossref Scopus (11) Google Scholar, 11Cheng D.C.H. Fast-track cardiac surgery: Economic implications in postoperative care.J Cardiothorac Vasc Anesth. 1998; 12: 72-79Abstract Full Text PDF PubMed Scopus (88) Google Scholar, 12Salhiyyah K. Elsobky S. Raja S. et al.A clinical and economic evaluation of fast-track recovery after cardiac surgery.Heart Surg Forum. 2011; 14: E330-E334Crossref PubMed Scopus (23) Google Scholar Time of day may limit the potential for early extubation in both models, with a general reluctance to extubate patients overnight. Hwang et al. demonstrated that most postoperative cardiac surgical patients admitted to an ICU were extubated between 7 am and 8 pm, with relatively few patients extubated overnight, despite a protocol aiming for early extubation within 4 hours of arrival in the ICU.13Hwang N.C. Shankar S. Ong B.C. et al.Changing the institutional practice of prolonged mechanical ventilation after coronary artery bypass graft surgery to early extubation.Ann Acad Med Singapore. 1999; 28: 534-541PubMed Google Scholar This potentially could affect patients operated on later in the day. Bhavsar and Jakobsen demonstrated that this was a potential issue that limited any further reduction in ICU LOS; however, despite this, there was no significant impact on hospital LOS.4Bhavsar R. Jakobsen C.J. Are fast-track protocols a myth and the decrease in resource utilisation simple demographics?.J Cardiothorac Vasc Anesth. 2020; 34: 1476-1484Abstract Full Text Full Text PDF Scopus (2) Google Scholar Thirdly, physiological factors such as cardiorespiratory stability, temperature, and metabolic acidosis all determine time to extubation. Early complications such as bleeding requiring repeat surgical exploration or the requirements for high doses of inotropic agent support all may delay extubation. The use of a validated score to describe postoperative physiological status, such as the cardiac surgery score (CASUS), may have been beneficial in differentiating this. Exarchopoulos et al. compared CASUS with EuroSCORE II, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II, and Sequential Organ Failure Assessment for outcome prediction in patients after cardiac surgery and found CASUS to be the most reliable score for benchmarking and risk stratification in cardiac surgery patients.14Exarchopoulos T. Charitidou E. Dedeilias P. et al.Scoring systems for outcome prediction in a cardiac surgical intensive care unit: A comparative study.Am J Crit Care. 2015; 24: 327-334Crossref PubMed Scopus (23) Google Scholar Youssefi et al. retrospectively reviewed the incidence of FT failures in a study of 451 patients.15Youssefi P. Timbrell D. Valencia O. et al.Predictors of failure in fast-track cardiac surgery.J Cardiothorac Vasc Anesth. 2015; 29: 1466-1471Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Overall, 36% of patients failed FT, of whom 83.3% required ICU admission on the day of surgery, and 16.7% required late ICU admission from the ward. Multivariate analysis revealed that predictors of FT failure included reduced renal function, hypertension, age, EuroSCORE, cardiopulmonary bypass time, initial lactate or base deficit after surgery, and cross-clamp time. The strongest preoperative predictor of FT failure was glomerular filtration rate less than 65 mL/min/body surface area. While there was no mortality in the patients selected for FT, those who failed FT and required ICU admission required a longer hospital LOS (7 v 5 days). The key application of Jakobsen and Bhavsar's study is the potential to identify patients who may benefit from PACU-based postoperative care after cardiac surgery accurately. Patients with lower comorbidity scores undergoing less complicated surgery may be expected to require a shorter duration of ventilatory and hemodynamic support after cardiac surgery and have lower CASUS scores. No conflict of interest to declare. The Major Decrease in Resource Utilization in Recent Decades Seems Guided by Demographic Changes: Fast Tracking—Real Concept or DemographicsJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 6PreviewTo identify dynamics of associations and potential areas for optimization of patient turnover between various patient profile and comorbidity indicators and selected system performance indicators such as ventilation time, length of stay in the intensive care unit, and in-hospital stay. Full-Text PDF