Fast-track Failure Research Articles

Factors associated with an unsuccessful fast-track course following minimally invasive surgical mitral valve repair

Analyses of fast-track (FT) processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure (FTF) in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery. Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of FTF consisted of >10 h mechanical ventilation, >24 h intensive care unit stay, reintubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with FTF. In total, 491 patients were included in the study and were analysed. Two hundred and thirty-seven patients (48.3%) failed the FT protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥III [odds ratio (OR) 2.05; 95% confidence interval (CI) 1.38-3.08; P < 0.001], pre-existing chronic kidney disease (OR 2.03; 95% CI 1.14-3.70; P = 0.018), coronary artery disease (OR 1.90; 95% CI 1.13-3.23; P = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; 95% CI 2.81-36.01; P < 0.001) and procedure time (OR 1.01; 95% CI 1.01-1.01; P < 0.001) were independently associated with FTF. Factors associated with FTF in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed FT.

Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up

An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. A retrospective cohort study. A single academic center. Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve=0.676; 95% confidence interval, 0.611-0.741). Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.

A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol.

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55–120) min vs. off-pump 80 (55–120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.

A retrospective comparison of on- and off-pump coronary artery bypass surgery undergoing fast track protocol

Introduction Fast track treatment, especially in a specialized recovery area, is a safe alternative for patients with low to moderate risk after surgery and leads to a reduced ventilation time as well as a shorter stay in the intensive care unit especially.1The benefit of fast track in off-pump vs on-pump coronary artery bypass patients is unclear. The aim of the study was the comparison of on- vs off-pump coronary artery bypass surgery undergoing fast track protocol. Primary endpoints are ventilation time and primary fast track failure. Primary fast track failure is defined as unplanned transfer from the recovery area to the intensive care unit or back to the operating theatre. Secondary endpoints include length of stay in recovery area, intermediate care unit and hospital, postoperative complications and secondary fast track failure (patients transferred from intermediate care or ward back to the intensive or intermediate care unit). Methods This retrospective observational study was performed in a single centre heart centre. Between September 2012 and December 2018 n= 3505 consecutive patients after coronary artery bypass surgery underwent fast track protocol. Patients after on-pump coronary artery bypass surgery were compared with patients after off-pump coronary artery bypass surgery using propensity score matching. Matching criteria included: age, gender, BMI, logistic Euroscore, preoperative ejection fraction, co-existing diseases, operative time and risk factors. Values are expressed as percentage or mean value ± standard deviation. Results After propensity score matching 926 patients were included in each group. There were no significant differences in demographic data after matching. Time to extubation showed no significant difference between both groups (on-pump 75 (55-120) min vs off-pump 80 (55-120) min, p=0,973). Primary and secondary fast track failure were also not significantly different between the groups with 8.2% vs 6 % and 12.9% vs 12.3% in on-pump vs off-pump group. There were no significant differences between both groups in terms of postanaesthetic care length of stay (on-pump 265 (83) min vs off-pump 270 (85) min, p=0,702), intermediate care length of stay (on-pump 53,6 (56) h vs off-pump 50 (56) h, p=0,316) and hospital length of stay (on-pump 9,9 (5,3) d vs off-pump 9,6 (5,4) d, p=0,256). Postoperative complications were comparable except for a significant difference in postoperative bleeding. Patients receiving off-pump coronary artery bypass surgery had a significant (p Discussion In conclusion, on- and off-pump coronary artery bypass surgery seem to be comparable in terms of fast track success. Any difference between the two approaches may be only attributed to the difference in the preoperative risk profile and length of surgery.

Fast-track off-pump coronary artery bypass: single-center experience.

The primary goal of the study was to perform retrospective analysis of fast-track coronary artery bypass grafting at our institute to identify risk factors for prolonged hospital stay. A secondary goal was to identify and compare survival statistics with those published in literature. We performed a retrospective analysis of patients enrolled in our fast-track coronary artery bypass protocol. There were 709 patients with a mean age of 58.85 ± 8.9 years; 572 were men. The mean EuroSCORE II was 2.02% ± 2.64%. Of these 709 patients, 538 (76%) met the requirements for discharge within 100 hours. Prolonged ventilation or reintubation, major pulmonary complications, gastrointestinal and neurological complications were the strongest predictors of fast-track failure. Persistent atrial fibrillation, postoperative transient renal impairment, requirement for noninvasive ventilation > 3 times, sternal wound infection, insulin-dependent diabetes mellitus, preoperative intraaortic balloon pump for chest pain or ST changes, preoperative severe left ventricular dysfunction, preoperative severe renal impairment, and peripheral arterial disease were also found to be significant risk factors for fast-track failure. Cumulative survival at 66 months of follow-up was 90.2% ± 0.02%. The risk factors listed above were associated with fast-track failure. Smoking cessation helps to nullify the factor of chronic obstructive pulmonary disease. Intraoperative elective insertion of a balloon pump does not affect the fast-track protocol. Survival was comparable to that described in the literature.

Factors Determining Fast-Track Failure Post Cardiac Surgery

Fast track protocol has been proven to be cost effective and allows optimal utilization of healthcare services. Careful patient selection is crucial to its success. We aim to identify factors leading to fast track failure in our institution so as to improve patient selection.

Predictors of Successful Fast Track Protocol in Transfemoral Transcatheter Aortic Valve Implantation Under General Anaesthesia

Objectives: There is no consensus about the optimal length of hospital stay in patients undergoing elective transfemoral TAVR under general anesthesia. Our study tried to find predictors of failure of early discharge strategy in those patients. Methods and results: We included retrospectively 135 high risk TAVI patients (mean Log. EuroSCORE 30.8 ± 6) operated under general anaesthesia between June 2017 and January 2018 in central hospital, Bad Berka, Germany. Focus on the preoperative factors was established in favor to find possible predictors of longer hospital stay in this group of patients. Uni- and multivariate analysis were performed to identify independent preoperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the hospital five days after surgery. Independent predictors of fast-track protocol failure were NYHA IV (OR 4.3; CI 95% 2.3-25, p-Value 0.017), ejection fraction (EF) ≤ 30% (OR 3.5; CI 95% 2-12.5, p-Value 0.006), right bundle branch block (OR 4.7; CI 95% 1.25-25, p-Value 0.03) and stroke with residual disability (OR 4.5; CI 95% 1.1-16, p-Value 0.025). Conclusion: NYHA IV, severely reduced ejection fraction, right bundle branch block and stroke with residual disability might be considered potential predictors of failure of fast track protocol in patient undergoing TAVI under general anesthesia.

Effect of motor subtypes of delirium in the intensive care unit on fast-track failure after cardiac surgery

ObjectiveThe purpose of the study was to evaluate the association between motor subtypes of postoperative delirium in the intensive care unit and fast-track failure (a composite outcome of prolonged stay in the intensive care unit >48 hours, intensive care unit readmission, and 30-day mortality) after cardiac surgery. MethodsThis was a secondary analysis of a prospective cohort study of 600 consecutive adults undergoing cardiac surgery at a university hospital in Hong Kong (July 2013 to July 2015). The motor subtypes of delirium were classified using the Richmond Agitation Sedation Score and Confusion Assessment Method intensive care unit assessments performed by trained bedside nurses. A generalized estimating equation was used to estimate a common relative risk of fast-track failure associated with motor subtypes. ResultsThe incidences of hypoactive, hyperactive, and mixed motor subtypes were 4.3% (n = 26), 4.0% (n = 24), and 5.5% (n = 33), respectively. Fast-track failure occurred in 88 patients (14.7%). There was an association between delirium (all subtypes) and fast-track failure (P = .048); hyperactive delirium (relative risk, 1.95; 95% confidence interval, 0.96-3.94); hypoactive delirium (relative risk, 2.79; 95% confidence interval, 1.34-5.84); and mixed delirium (relative risk, 2.55; 95% confidence interval, 1.11-5.88). Hypoactive and mixed subtypes were associated with prolonged intensive care unit stay (both P = .001). ConclusionsPatients with pure hypoactive delirium had a similar risk of developing fast-track failure as other motor subtypes. Differentiation of motor subtypes is unlikely to be clinically important for prognostication of fast-track failure. However, because delirium is associated with poor outcomes, potential treatment strategies should address all subtypes equally.

Predictors of Failure in Fast-Track Cardiac Surgery.

Fast-track (FT) management of cardiac surgery patients is associated with early extubation and reduced length of intensive care unit (ICU) stay, with potential benefit of reduced hospital costs. The authors examined perioperative factors and their influence on failure of FT and what implications this failure had. Prospective data collection from all adult cardiac surgeries between 2011 and 2013. Single-institution study. The study included 2,770 consecutive adult cardiac surgery patients. All participants underwent adult cardiac surgeries. Of those, 451 (16.3%) patients were selected to undergo FT management. Failure of FT was defined as early (admission to ICU on day of surgery) or late (patients later admitted to the ICU from the ward). Univariate and multivariate regression analyses were used to identify which variables predicted FT failure. Of the 451 patients included in this study, 138 (30.6%) failed the FT, with 115 (83.3%) early failures and 23 (16.7%) late failures. Predictors of failure were reduced renal function, hypertension, age, EuroSCORE, cardiopulmonary bypass time, first lactate or base deficit after surgery (all p<0.01), and cross-clamp time (p<0.05). Multivariate analysis showed that the strongest predictor of failure was glomerular filtration rate (GFR)<65 mL/min/BSA (sensitivity, 54%; specificity, 61%; likelihood ratio, 1.39; area under receiver operating characteristics curve, 0.59; 95% confidence interval, 0.53-0.64). Median length of hospital stay was longer for the failed group (5 v 7 days, p<0.001). There were no mortalities in any of the patients selected for FT. A number of perioperative factors are associated with failure to FT, the strongest predictor being GFR. Failure to FT can lead to significantly longer hospital stay.

Independent Risk Factors for Fast-Track Failure Using a Predefined Fast-Track Protocol in Preselected Cardiac Surgery Patients.

The purpose of this study was to identify the independent risk factors for fast-track failure (FTF) in cardiac surgery patients. A retrospective analysis. A university-affiliated heart center. In a 2-year period, 1,704 consecutive preselected patients undergoing elective cardiac surgery were treated according to the local fast-track protocol in the postanesthetic care unit (PACU), bypassing the intensive care unit (ICU). Independent risk factors for FTF in the univariate regression analysis were tested in a multivariate regression analysis. FTF was defined as any transfer of the preselected patient to the ICU. FTF was primary when the patient was transferred directly from the postanesthetic care unit to the ICU and secondary when the patient was transferred from the intermediate care unit or ward to the ICU. FTF rate was 11.6% for primary and 5.6% for secondary FTF. In the multivariate regression analysis, age>70 years, female sex, prolonged surgery, and prolonged cross-clamp time could be defined as independent risk factors for FTF. In a preselected patient population, fast-track treatment could be done with a low FTF rate. Independent risk factors for FTF are age, female sex, prolonged surgery, and prolonged cross-clamp time.

Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study

A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. Prospective randomized study. All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. One hundred twenty patients were assigned randomly into 2 groups (60 in each group). Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting.

Fast-Track Failure After Cardiac Surgery

To facilitate the planning of perioperative care pathways, a fast-track failure prediction model has been developed in patients undergoing cardiac surgery. This study externally validated such a fast-track failure risk prediction model and determined the potential clinical consequences to ICU bed utilization. Prospective cohort study. Cardiothoracic Surgery Department and Intensive Care Unit of Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong. The St. Mary's Hospital fast-track failure risk prediction model was applied to patients included in an adult cardiac surgery database (January 2006 to June 2011). The performance of the fast-track failure risk model was assessed by discrimination and calibration methods. The potential clinical consequences of applying the model on ICU bed utilization was assessed using a decision curve analysis. Of the 1,597 patients, 175 (11%) failed fast-track management. The final updated model showed very good discrimination (area under the receiver operating characteristic curve = 0.82, 95% confidence interval 0.78-0.86) and adequate calibration (Hosmer-Lemeshow goodness-of-fit statistic, p = 0.80). A decision curve analysis showed that if a threshold probability range of fast-track failure of 5% to 20% is used to determine who should be electively admitted to the ICU and who should be admitted to a fast-track recovery unit, it would lead to a substantial benefit (23%-67%) in terms of effective bed utilization, even after taking into account the negative consequences of unplanned admissions. As the performance of the final updated fast-track failure model was very good, it can be used to estimate the predicted probability of fast-track failure on individual patients. The clinical consequence of applying the final model appears substantial with regard to the potential increase in effective ICU bed utilization.

Fast-track failure after cardiac surgery: Development of a prediction model*

Risk factors for unsuccessful fast-tracking of cardiac surgery patients have not been collectively defined in the literature. The aim of this study was to determine risk factors for fast-track failure and incorporate them into a predictive fast-track failure score. Prospective observational study. Cardiothoracic Department of St Mary's Hospital, London. Data were collected from April 2003 to April 2005 including 1,084 patients undergoing heart surgery who were admitted into the fast-track unit. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of fast-track failure. One hundred and sixty-nine patients failed fast-track management (15.6%). Independent predictors for fast-track failure were impaired left ventricular function with or without recent acute coronary syndrome (odds ratios 2.89 and 1.65 respectively), re-do operation (one, two, or more vs. none, odds ratio 1.75, 7.98), extracardiac arteriopathy (odds ratio 2.63), preoperative intra-aortic balloon pump (odds ratio 3.09), raised serum creatinine in micromol/L (120-150, >150 vs. <120, odds ratio 1.57, 11.24), and nonelective (odds ratio 3.43) and complex surgery (odds ratio 2.70). Model validation showed very good discrimination (area under the curve = 0.815) and calibration (ĉ statistic = 8.527, p = .129). The fast-track failure score incorporates several preoperative factors and has been successfully internally validated; after undergoing external validation and possible recalibration it may be used as a tool to facilitate planning and flow of cardiac surgery patients, based on the predicted probability of failure. Application of this score may limit fast-track failure rates and help to reduce morbidity and cost.

A new scoring system to predict fast-track failure in cardiac surgery*

A new scoring system to predict fast-track failure in cardiac surgery*

Simplified Parsonnet risk scale identifies limits to early patient discharge.

Fast-track recovery after coronary artery bypass surgery has influenced patient care positively. Predicting patients who fall off track and require prolonged (> or =7 days) hospitalization remains uncertain. The Parsonnet risk assessment score is effective in predicting length of stay, but is limited by inaccurate subdivision of risk categories. We simplified the Parsonnet risk scale to better identify patients eligible for fast-track recovery. The cases of 604 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) were reviewed retrospectively. A rapid recovery protocol emphasizing reduced CPB time, preoperative intra-aortic balloon pump (IABP) criteria, and atrial fibrillation prophylaxis was applied to all patients. The five original divisions of the Parsonnet risk scale were reduced to three risk categories: Low (0-10; Group A), Intermediate (11-20; Group B), High (> 20; Group C). Comparisons of progressive risk categories were analyzed to identify predictive factors associated with fast-track outcomes. The thirty-day operative mortality for the entire group was 3.6%. Three clinical features were identified that distinguished risk progression-female gender, reoperative CABG, and increased age. Additionally, the presence of diabetes (p < 0.05), congestive heart failure (p < 0.01), and peripheral vascular disease (p < 0.001) distinguished Groups A and B, while acute myocardial infarction (p < 0.05) influenced outcomes in Group C. Group A (48%) mean risk score 5.9+/-3.2 was compared to Group B (34%) 14.8+/-2.6, which was further compared to Group C (18%) 26.4+/-2.8. The mean length of stay for Group A (5.3+/-4.1 days) was notably less than Group B (6.1+/-4.7 days; p < 0.05); however, both groups responded favorably to fast-track techniques. Group C did not respond comparably (9.2+/-9.2 vs 6.1+/-4.7 days; p < 0.001) and experienced prolonged recovery. The simplified Parsonnet risk scale did not identify differences in operative mortality and revealed only pneumonia (p < 0.05) and atrial fibrillation (p < 0.01) to be greater in Group C. As risk increased, significantly less revascularization was performed (Group A 3.6+/-1.2 grafts/patient vs Group B 3.3+/-1.2 [p < 0.01]; Group B 3.3+/-1.2 vs Group C 2.5+/-1.0 [p < 0.001]). A simplified Parsonnet risk scale (three categories) is an effective tool in identifying factors limiting fast-track recovery. Low- and intermediate-risk patients represent the majority (82%) and respond well to fast-track methods. High-risk patients (18%) are limited by a greater percentage of female patients, reoperative CABG, and the very elderly, resulting in fast-track failure. Strategies to improve recovery in high-risk patients may include evolving off-pump techniques.

Politics Matter: The 1997 Derailment of Fast-Track Trade Authority

In 1997, President Clinton became the first President not awarded fast-track trade negotiating authority since this congressional delegation of trade policymaking authority first began in 1934. Fast-track's failure also represents a case of an unsuccessful business political strategy since business supporters of the measure were easily defeated by labor and environmental opponents, despite the many political ‘privileges’ that business possessed. This case study describes why fast-track is important to the future of US and global trade policy and examines the main reasons for its failure. In doing so, it illustrates theories of pivotal politics, the median voter, collective action, issue framing, international trade's welfare costs and benefits, and international relations that often arise in research and courses on the non-market environment of business, international trade, and international political economy.

The Politics of Trade: Fast Track's Failure Derails the New Economy

No abstract available.