Fast-track Group Research Articles

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BackgroundAn optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.MethodsThis retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.ResultsWe included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39–11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.ConclusionImplementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.Trials registrationThe study protocol was registered in the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/ACTRN12623000060640.aspx, retrospectively registered on 17/01/2023).

Fast-track recovery after surgery for perforated peptic ulcer safely shortens hospital stay: A systematic review and meta-analysis of six randomized controlled trials and 356 patients.

Postoperative management after surgery for perforated peptic ulcer is still burdened by old traditions. All available data for fast-track recovery in this setting are either very unspecific or underpowered. The aim of this study was to evaluate fast-track recovery in this diagnosis-specific context in a larger sample. Electronic data sources were searched. Eligible studies were randomized controlled trials (RCTs) comparing fast-track recovery and traditional management after surgery for perforated peptic ulcer in adults. A systematic review and meta-analysis was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines regulated the process. Quality and risk of bias assessments of individual RCTs were performed by means of the Let Evidence Guide Every New Decision criteria and the Cochrane risk-of-bias tool. Primary endpoints were length of hospital stay and risk of complications. Random or fixed effects modeling were applied as indicated. Outcomes were measured by mean difference and risk difference. Six RCTs with a total cohort of 356 patients were included. Results of our meta-analysis showed significantly shortened length of hospital stay (mean difference -3.50days [95% CI -4.51 to -2.49], p≤0.00001), significantly less superficial and deep surgical-site infections (risk differences -0.12 [95% CI -0.20, -0.05], p=0.002 and -0.03 [95% CI -0.09, 0.03], and p=0.032, respectively), and significantly fewer pulmonary complications (risk difference -0.10 [95% CI -0.17, -0.03], p=0.004) in the fast-track group. This systematic review and meta-analysis shows that fast-track recovery after surgery for perforated peptic ulcer significantly shortened hospital stay in the studied cohort without increasing the risk of postoperative complications.

On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery.

Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery. Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home. Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7. Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.

Effects of fast-track recovery programme on the surgical site wound infection in patients undergoing biliary stones surgery: A meta-analysis.

To systematically evaluate the effects of a fast-track recovery programme on perioperative wound infections and postoperative complications in patients undergoing biliary tone surgery, we conducted a comprehensive search of PubMed, Web of Science, Cochrane Library, Embase, China Biomedical Literature Database, Wanfang and China National Knowledge Infrastructure databases from inception to 29 September 2023 for randomised controlled trials (RCTs) focusing on the application of a fast-track recovery programme in patients undergoing biliary stone surgery. Two researchers independently screened and evaluated the studies based on predefined inclusion and exclusion criteria, and data were subsequently extracted from the included studies. Stata software (version 17.0) was employed for data analysis. Overall, 19 RCTs involving 2363 patients were included, with 1178 patients allocated to the fast-track recovery programme group and 1185 to the conventional care group. The results revealed a significantly lower occurrence of wound infection (3.74% vs. 9.45%, OR = 0.36, 95% CI: 0.25-0.51, p < 0.001) and postoperative complications (11.38% vs. 27.34%, OR = 0.31, 95% CI: 0.25-0.39, p < 0.001) in the fast-track recovery programme group compared to the conventional care group. The available evidence supports the assertion that implementing a fast-track recovery programme in the perioperative period of patients undergoing biliary stone surgery effectively reduces the incidence of wound infections and postoperative complications while facilitating postoperative recovery.

Comparison Between Fast-Track and Conventional Anesthesia for Children Undergoing Closure of Ventricular Septal Defects: A Systematic Review and Meta-Analysis.

Ventricular septal defect (VSD) is common in pediatric patients. This study aimed to evaluate the safety and effectiveness of using fast-track anesthesia and comparing it to traditional anesthesia, among children undergoing a transthoracic device closure for VSD. A systematic review following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Relevant literature was identified through specific search terms in the Scopus, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (Embase), Web of Science, TheCochrane CentralRegister of Controlled Trials (CENTRAL), and Google Scholar databases. The inclusion criteria focused on observational studies that compared fast-track anesthesia with conventional anesthesia in pediatric VSD closure cases. Data extraction, quality assessment, and meta-analysis were performed using standard differences in means. Initially, 6,535 papers were identified, and subsequent screening of titles and abstracts led to the inclusion of four retrospective studies from a total of 51 studies. The analysis encompassed 477 patients, with 235 in the fast-track anesthesia group and 242 in the conventional anesthesia group. No statistically significant disparities were observed between the two groups concerning the operative duration and hemodynamic variations post-intubation or post-procedure (P >0.05). Nevertheless, the fast-track anesthesia group demonstrated significantly reduced healthcare expenses as well as shorter periods of mechanical ventilation, ICU stay, and overall hospitalization compared to conventional anesthesia (P <0.05). The use of fast-track anesthesia in combination with transthoracic device closure for VSD demonstrates a safe and effective approach for pediatric patients. This approach results in reduced healthcare costs (10,000 Renminbi (RMB)) and shorter durations of mechanical ventilation, ICU admission, and hospitalization compared to conventional anesthesia. Further clinical trials are necessary to confirm these results and assess long-term outcomes.

Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment.

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

Ultra Fast-Track Vs Conventional Fast-Track in Patients Undergoing Cardiac Surgery: A Propensity Score Matched Analysis.

We aimed at comparing the risk of major adverse events and length of stay between patients undergoing ultrafast-track and conventional fast-track. Retrospective cohorts study adjusted by propensity score matching, including patients operated on between March-2020 and December-2022 of any of the following: coronary, valve surgery or ascending aorta surgery. Patients were divided in two groups: ultrafast-track: extubation in the operating room and fast-track: extubation attempted in the first 6 postoperative hours. The primary objective was to compare the risk of the combined event death, lung respiratory outcomes (reintubation, mechanical ventilation longer than 24hh or pneumonia), or acute renal failure. 1126 patients were included. 579(51.4%) were extubated in the operating room. 331 pairs were available after matching by propensity score. The risk of the primary outcome was 11.8%(n = 39) in the fast-track group and 6.3%(n = 21) in the ultrafast-track group(p = 0.013), mostly driven by lung adverse events (6.9% Vs 2.4%,p = 0.011) while no significant differences were detected in the risk of death (2.4% Vs 1.8%,p = 0.77) or acute renal failure (8% Vs 6.3%,p = 0.56). The risk of myocardial infarction was higher in the fast-track group (2.7% Vs 0%,p = 0.039). The median length of stay in the postoperative intensive care unit was longer in the fast-track group (24.7hh(IQR 21.5; 62.9) Vs 23.5hh(IQR 22; 46),p = 0.015). In patients undergoing cardiac surgery, extubation in the operating room is associated to a lower risk of postoperative complications (mostly driven by lung adverse events) and length of stay in intensive care unit as compared to fast-track.

Fast vs. Regular Track for Lung and Pancreatic Cancer Diagnosis-Time from Initial Finding to Final Diagnosis and Patient Survival.

Health systems around the world have begun implementing unique tracks to expedite diagnosis and improve survival of patients with suspected cancers. This study aimed to compare characteristics and survival between patients diagnosed by way of fast and regular diagnostic tracks. A historical cohort study of patients (age ≥ 18) diagnosed with lung or pancreatic cancers between 09/2017 and 03/2020 on a fast diagnostic track and treated in a tertiary hospital versus a random sample of patients with the same cancer types who began treatment in the hospital over the same period of time after being diagnosed utilizing the regular track in the community. The study included 336 patients (108 fast-track diagnostics, 228 regular track diagnostics). Advanced stages III-IV at diagnosis were more likely in the fast-track group (94.4% vs. 81.1%, p = 0.001). The median time from initial cancer suspicion to diagnosis was 21days (IQR 14-37) for the fast-track vs. 31days (IQR 18-51) for the regular track (p < 0.001). During the follow-up period, 56 patients from the fast-track and 131 patients from the regular track died. No significant difference was found in the median survival time between the fast and regular tracks, whether from the onset of symptoms, diagnosis, or treatment initiation. Patients referred to the fast-track were more likely to be diagnosed at a further advanced stage of their cancer. The fast-track shortened the time until diagnosis and treatment but no difference was found in median survival between the tracks, perhaps due to late referral and high fatality rates.

Fast Track Liver Transplantation: Lessons learned after 10 years running a prospective cohort study with an ERAS-like protocol

Fast Tracking in Liver Transplantation has been around for the past 25 years, although no substantial advancement, in the form of a comprehensive protocol, had been readily available. Few centers had embraced this goal, so before we started our program, a little over a decade ago, we adopted most of these ideas into a comprehensive pathway that would swiftly carry our patients from the preoperative stage through a safe home discharge. From day one, we have used this Fast Track pathway and applied it prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our results after 10 years. Patients and MethodsAll liver transplants performed at our center for the first 10 years since the start of the program (September 2012–September 2022) were included. Our standard protocol included balanced general anesthesia, fluid restriction, avoidance of transfusions, inferior vena cava preservation with temporary porto-caval shunt and thromboelastography. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. Results385 transplants were performed in 367 patients (287♂/80♀) over 120 months, mean age 57.4±9.5 years, raw MELD score 15.4±8.1. Predominant etiologies were alcohol (n=217) and HCV (n=108), with hepatocellular carcinoma present in 197 (53.7%). Eighteen patients underwent combined liver-and-kidney transplants. Mean operating time was 313±66 min with cold ischemia times of 281±85 min. Fifty-nine patients (15.3%) were transfused in the OR (2.3±1.1 units of PRBC). Extubation was immediate (< 30 min) in 365 cases (94.8%). Median ICU length of stay was 12.6 h, and median post-transplant hospital stay was 4 days (2–97) with 55 patients (15.8%) discharged home by the 2nd day, 141 (40.5%) by the 3rd day and 203 (58.3%) by the 4th day, which defined our Fast-Track group. The overall thirty-day-readmission rate was (34.5%), which became significantly lower (27.6% vs 44.1%, p=0.0014) in the Fast-Track group when compared to the regular discharge group. Patient survival was 87.6% at 1 year and 79.7% at 5 years. ConclusionFast-Tracking of Liver Transplant patients is very feasible and can be applied as the standard of care.

Early Experience With an Endocrinology Preoperative Fast-Track Program for Optimizing Spine Surgery Candidates With Poorly Controlled Diabetes Mellitus.

Previous studies demonstrated an increase in adverse outcomes for patients undergoing elective surgeries with poorly controlled diabetes mellitus. At a large, tertiary-care spine center with a notable population of patients with poorly controlled diabetes, an Endocrinology Fast-Track (EFT) program was developed to improve patient optimization before elective spine surgery. The purpose of this study was to report our early experience. Seventy-five patients who were scheduled for elective spine surgery were noted to have Hgb A1c > 7 on preoperative evaluation. Thirty-two patients accepted referral to the EFT program and 43 declined (non-EFT). Mean preoperative Hgb A1c was similar between groups (EFT: 8.79 versus non-EFT: 9.26, P = 0.221). The Fast-Track program included counseling, education, and medical management. Patients in the two groups were similar in number of females (EFT: 17 versus non-EFT: 17, P = 0.348), age (EFT: 57.7 versus non-EFT: 60.6, P = 0.280), and body mass index (EFT: 34.6 versus non-EFT: 33.0, P = 0.341). A smaller number of smokers were there in the EFT group (1) compared with the non-EFT group (15, P = 0.003). The proportion of patients on insulin (EFT: 19 versus non-EFT: 23, P = 0.814) and oral hypoglycemics (EFT: 29 versus non-EFT: 39, P = 0.983) was similar between the two groups. Surgical clearance for patients with a documented preoperative Hgb A1c of < 7 or equivalent fructosamine level was significantly better in the Fast-Track group compared with the non-Fast-Track group (91% versus 42%, P = 0.000). Although most patients who declined the Fast-Track program did not obtain clearance for surgery, mean Hgb A1c was improved at the latest follow-up in both groups for those who obtained surgical clearance (7.10 versus 6.78, P = 0.470). A novel EFT program was successful in obtaining acceptable blood glucose control in patients recommended for spine surgery who had poorly controlled diabetes mellitus on preoperative evaluation. The improved blood glucose control was maintained at the latest follow-up.

Fast-track protocols in proximal aortic repair: teamwork makes the dream work.

It is not news that patients and, with them, the whole medical and scientific world are attracted to the prospect of less-invasive procedures in cardiac surgery. During the last decades, the concept of invasiveness has classically been linked to the size of the skin incision, but it also concerns the surgical and cardiopulmonary bypass techniques and the anaesthetic management. Fast-track protocols in cardiac surgery are aimed at early extubation and a shortened Intensive Care Unit (ICU) stay. These techniques have proved to be safe in low- or moderate-risk patients [1], but they have mostly been used in patients undergoing CABG procedures and minimally invasive mitral or aortic valve surgery. In their recent manuscript, Leipzig’s group [2] provided interesting data showing how fast-track protocols can be applied in complex aortic surgery as well. Using a propensity score matching, the authors compared 197 elective Bentall procedures who underwent conventional perioperative management with 197 patients receiving a fast-track protocol. The latter were subjected to early extubation in a postoperative anaesthetic care unit and then transferred to the intermediate care unit. Their retrospective study showed non-inferiority in the fast-track group, with no difference in intraoperative, intrahospital and follow-up outcomes. The fast-track group obviously presented shorter ICU stays (6.7 vs 21.7 h) and ventilation times (165 vs 517 min), but there was no difference in the total hospital stay [2]. The manuscript is well written and results are consistent.

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients.

Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk. We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months. A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications. In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot. Level II, prospective comparative study.

Effect of Fast-Track Surgery under ERAS protocol in Laparoscopic Hysterectomy: A Randomized Controlled Trial

Background & Objective: Fast-track surgery (FTS) consists of different pathways to decrease surgical complications and improve outcomes and patient satisfaction. FTS in an elective gynecologic laparoscopic surgery has not been well assessed. No consensus guidelines have been developed for gynecologic laparoscopic surgeries. The purpose of this study is to evaluate enhanced recovery after surgery (ERAS) for total laparoscopic hysterectomy.Materials & Methods: 260 patients underwent for laparoscopic hysterectomy surgery. All patients were divided into two groups as follows: one group received traditional laparoscopic hysterectomy surgery and the intervention group was treated under ERAS protocol. ERAS protocol includes not receiving preoperative mechanical bowel preparation and laxatives as well as fasting 6 h and not drinking liquids 2h before surgery. The patients were allowed to resume the ordinary diet 6h post-operation. Ondansetron 4 mg were prescribed after surgery for nausea and vomiting, pain was controlled with non-narcotic analgesics diclofenac suppository 100 mg/q12 h and paracetamol 1000 mg/q6 h until discharge. Urinary catheter was removed whenever possible and early ambulation occurred 6h after the surgery.Results: A total of 260 patients were studied. Regarding the length of hospitalization, significant differences were shown between the groups (P<0.001). Return to daily functions was occurred earlier in the fast-track surgery group than another group. Complications and VAS pain scores showed no significant differences between the groups.Conclusion: Our results show that ERAS surgery has fewer side effects and better outcomes which make it more suitable for patients undergoing laparoscopic hysterectomy.

The Role of Fast Track Extubation in Enhance Recovery after Pediatric Cardiac Surgery

Background: By allowing patients to be extubated from their ventilators in the intensive care unit (ICU) as soon as they have stabilized, fast-track anesthesia (FTA) hastens the return to full awareness and independent breathing after surgery.&#x0D; Objective: In this study our main goa is to evaluate the role of fast track extubation in enhance recovery after pediatric cardiac surgery.&#x0D; Method: This prospective study was carried out at tertiary hospital from January 2021 from January 2022 where total of 200 CHD children, aged 6 months to 2 years and admitted to tertiary hospital, were selected for this study. During the study, 200 patients were randomly divided into two groups each consisting of 100 patients, and were subjected to fast track anesthesia and conventional anesthesia before surgeries.&#x0D; Results: During the study, in fast track anesthesia group mean age was 1.2 ± 0.5 years, followed by 55 cases were female, 47 were preterm patients, mean anesthesia times was 3.5 ± 1.2 h, mean surgery time was 295.1 ± 22.9 min, mean CPB time was 47.2 ± 11.8, mean block time or a total allocated amount of time for a surgeon was 30.2 ± 8.9. whereas in conventional anesthesia group, mean age was 1.1 ± 0.5 years, followed by 40 cases were female, 45 were preterm patients, mean anesthesia times was 3.2 ± 1.0 h, mean surgery time was 288.0 ± 20.5 min, mean CPB time was 46.2 ± 10.7, mean block time was 31.5 ± 9.1. in fast track group mean extubation time was 22.9 ± 3.5 min followed by mean postoperative hospital stay was 11.5 ± 3.0 days, besides that, at extubation SAS score was 3.8 ± 0.6a and 24h post operation SAS score was 4.0 ± 0.5. Whereas in conventional group mean extubation time was 189.1 ± 31.2 min followed by mean postoperative hospital stay was 16.1 ± 2.4, besides that, at extubation SAS score was 4.8 ± 0.7and 24h post operation SAS score was 3.9 ± 0.5. MAP, HR and CVP between children outcome was measured based different time interval (T0 to T5) Moreover, no significant changes were noticed between two group.&#x0D; The number of patients with ventilator-associated pneumonia was less in fast track group than in conventional group (P &lt; 0.05). In fast track group arrhythmia cases were seen in 1% cases followed by 1% infection cases were seen, bleeding seen in 1%. Whereas in conventional group arrhythmia cases were seen in 2% cases followed by 1% infection cases were seen, bleeding seen in 2%.&#x0D; Conclusion: Fast Track Anesthesia generates stable hemodynamics during operation, shorter extubation time, shorter ICU and hospitalization stay without increase in adverse reactions. It is worthy of recommendation for clinical practice.

Group-based pulmonary telerehabilitation is feasible, safe, beneficial and well-received in patients who have been hospitalised with COVID-19.

Coronavirus disease 2019 (COVID-19) has caused worldwide mass hospitalisation. The need for multidisciplinary post-hospitalisation rehabilitation is becoming increasingly apparent, and telerehabilitation has been endorsed. The aim of study was to investigate the feasibility and efficacy of pulmonary telerehabilitation for COVID-19 survivors. This was a single-centre, mixed-methods, fast-track (wait-list), randomised controlled trial of telerehabilitation for patients who had been hospitalised with COVID-19. 40 patients discharged from two university teaching hospitals in the north of England were recruited. Telerehabilitation consisted of 12 exercise classes, six education events and opportunity for peer support. Patients commenced telerehabilitation 14 days after randomisation in the fast-track group and 56 days after randomisation in the wait-list group. Descriptive and statistical improvements were noted in several clinical outcome measures. Exercise capacity increased from a median (interquartile range) 20 (14-24) sit-to-stand repetitions in 1 min at baseline to 25 (24-30) post-telerehabilitation. Breathlessness rated using the Medical Research Council dyspnoea scale changed from 3.5 (3-4) at baseline to 2 (1.5-3) post-telerehabilitation, with additional favourable outcomes noted in respiratory symptoms measured using numerical rating scales and visual analogue scales (VAS). Quality of life measured using the EuroQol VAS improved from 55 (60-70) units at baseline to 70 (55-80) units following telerehabilitation. Improvements in fatigue (modified Functional Assessment of Chronic Illness Therapy: Fatigue) and mood (Hospital Anxiety and Depression Scale - Depression) were also observed. Natural recovery was observed in the wait-list group prior to receiving telerehabilitation; however, improvements were accelerated by early telerehabilitation in the fast-track group. We have shown that group-based telerehabilitation is feasible, safe, beneficial and well-received in this population.

211.6: ERAS in Liver Transplantation: A Decade Running a Comprehensive Fast-track Liver Transplant Protocol

Introduction: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay (LOS), improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to- discharge) before starting our liver transplant activity and then applied this protocol prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We report our results after a decade of activity. Method: Prospective cohort study of all the liver transplants performed since we started our program in 2012. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and tempo- rary portocaval shunt were strategies common to all cases. Our standard pro- tocol for immunosuppression included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophe- nolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started very early. LOS data refers to patients who were discharged (either from ICU or from the hospital) after transplantation. Results: A total of 359 liver transplants have been performed in 341 patients (269M/72F) over 114 months, mean age 57.3±9.5 years, raw MELD score 15.2±7.8 (MELD-Na 17.1±8.1). Predominant etiologies were alcohol (n = 203) and HCV (n = 105), with hepatocellular carcinoma present in 187 (52.1%). Twenty-six transplants were URGENT (7%) and 15 of them were performed for Fulminant Hepatic Failure. Eighteen patients underwent combined liver and kidney transplants. The median operating time was 307 min (range 167–546) with median cold ischemia time of 267 min (130–628). We transfused PRBCs in the OR in 51 cases (14.2%) at an average of 2.4 ± 1.2 units per case. Median ICU LOS was 12.7 h, and median post-transplant hospital LOS was 4 days (2–82) with 52 patients (16.3%) going home by the 2nd posttransplant day, 133 (41.6%) by the 3rd, and 190 (59.4%) by the 4th, which defines the LOS of our fast-track group (2–4 days). Overall thirty-day-readmission rate was 34.7%, and it was significantly lower (27.9% vs. 44.6% P = 0.002) in the fast-track group. Patient survival was 88% at 1 year and 79% at 5 years for the entire series. Conclusion: Fast-Tracking of Liver Transplant patients is feasible and remains the standard of care for our entire liver transplant population.

110. Early experience with an Endocrinology FastTrack program for preoperative optimization of spine surgery candidates with poorly controlled diabetes mellitus

<h3>BACKGROUND CONTEXT</h3> Previous studies have shown an increase in adverse outcomes for patients undergoing elective surgeries with poorly controlled diabetes mellitus (preoperative Hgb A1c >7). Delays in surgical treatment for symptomatic spinal stenosis and related conditions can lead to significant patient dissatisfaction, prolonged pain, disability, immobility and neurologic decline. Patients with poorly controlled diabetes often lack sufficient knowledge and the access to care required to improve their blood sugar management preoperatively. At a large, tertiary-care spine center with a significant population of poorly controlled diabetic patients, an Endocrinology FastTrack (EFT) program was developed to improve patient optimization prior to elective spine surgery. <h3>PURPOSE</h3> The purpose of the current study is to report our early experience with an Endocrinology FastTrack (EFT) program to improve blood sugar management in diabetic patients before lumbar fusion surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> Patients scheduled for elective lumbar fusion surgery witha Hgb A1c > 7 on preoperative evaluation. <h3>OUTCOME MEASURES</h3> HbA1c, surgical clearance. <h3>METHODS</h3> Seventy-five patients who had been recommended for elective spine surgery were noted to have a Hgb A1c > 7 on preoperative evaluation. Thirty-two patients accepted referral to the Endocrinology FastTrack (EFT) program and 43 declined (Non-EFT). Mean preoperative Hgb A1c was similar between groups (EFT: 8.79 vs Non-EFT:9.26, p=0.221). The FastTrack program included counseling, education and medical management. <h3>RESULTS</h3> Patients in the two groups were similar in terms of number of females (EFT: 17 vs non-EFT:17, p=0.348), age (EFT:57.7 vs non-EFT:60.6, p=0.280) and BMI (EFT:34.6 vs non-EFT:33.0, p=0.341). There was a smaller number of smokers in the EFT (1) compared to the non EFT group (15, p=0.003). The proportion of patients on insulin (EFT:19 vs non-EFT:23, p=0.814) and oral hypoglycemic (EFT:29 vs non-EFT:39, p=0.983) was similar between the two groups. Surgical clearance for patients with a documented preoperative Hgb A1c < 7 or equivalent fructosamine level was significantly better in the FastTrack group compared to the non-FastTrack group (91% vs 42%, p=0.000). While the majority of patients who declined the FastTrack did not obtain clearance for surgery, mean Hgb A1c was improved at latest follow-up in both groups who obtained surgical clearance (7.10 vs 6.78, p=0.470). <h3>CONCLUSIONS</h3> A novel Endocrinology FastTrack program was successful in obtaining acceptable blood sugar control in patients recommended for spine surgery who had poorly-controlled diabetes mellitus on preoperative evaluation. The improved blood sugar control was maintained at latest follow-up. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Fast-Track Management of Concurrent Percutaneous Coronary Intervention in Patients Scheduled for Endovascular Abdominal Aortic Aneurysm Repair.

To investigate the safety and efficacy of fast-track management of concurrent percutaneous coronary intervention (PCI) in patients with abdominal aortic aneurysm scheduled for endovascular aortic aneurysm repair (EVAR). Eligible patients with abdominal aortic aneurysm who received EVAR from January 2011 to December 2019 were included in this retrospective cohort study. Propensity score (PS)-matched analysis was used to balance the baseline between the fast-track and standard control (EVAR without significant coronary artery disease) groups. Effects of fast-track management on short-term and midterm outcomes were evaluated via Cox proportional hazard regression and logistic regression analyses with corresponding hazard ratio (HR) or odds ratio (OR) and associated 95% confidence intervals (95% CIs), respectively. The study included 669 patients (73 fast-track and 596 standard control). Compared with the standard control group, no significant difference was found regarding major adverse cardiac events (HR 0.78, 95% CI [0.36, 1.68], p=0.519), overall mortality (HR 0.63, 95% CI [0.25, 1.55], p=0.315), and 30-day major hemorrhage events (OR 1.01, 95% CI [0.99, 1.03], p=0.514). The results were consistent in the PS-matched cohorts regarding major adverse cardiac events (HR 0.57, 95% CI [0.25, 1.29], p=0.176), overall mortality (HR 0.43, 95% CI [0.17, 1.11], p=0.820), and 30-day major hemorrhage events (OR 1.00, 95% CI [0.05, 10.61], p=0.999). Similar results were found in the subgroup analyses concerning fast-track management of 2-week intervals and patients with high age-adjusted Charlson comorbidity index. Under appropriate perioperative care, shortening the time interval between PCI and EVAR to 1 month, or even 2 weeks, seemed to be safe and effective. Short-term and midterm cardiovascular and survival outcomes were comparable with patients who underwent standard EVAR without significant coronary artery disease.

Client and healthcare worker experiences with differentiated HIV treatment models in Eswatini.

IntroductionUniversal access to antiretroviral therapy (ART) is a cornerstone of Eswatini’s national HIV strategy, and the number of people on ART in the country more than tripled between 2010 and 2019. Building on these achievements, the Ministry of Health (MOH) is scaling up differentiated service delivery, including less-intensive differentiated ART (DART) models for people doing well on treatment. We conducted a mixed-methods study to explore client and health care worker (HCW) perceptions of DART in Eswatini.MethodsThe study included structured site assessments at 39 purposively selected health facilities (HF), key informant interviews with 20 HCW, a provider satisfaction survey with 172 HCW and a client satisfaction survey with 270 adults.ResultsAll clients had been on ART for more than a year; 69% were on ART for ≥ 5 years. The most common DART models were Fast-Track (44%), Outreach (26%) and Community ART Groups (20%). HCW and clients appreciated DART, noting that the models often decrease provider workload and client wait time. Clients also reported that DART models helped them to adhere to ART, 96% said they were “very satisfied” with their current model, and 90% said they would recommend their model to others, highlighting convenience, efficiency and cost savings. The majority of HCW (52%) noted that implementation of DART reduced their workload, although some models, such as Outreach, were more labor-intensive. Each model had advantages and disadvantages; for example, clients concerned about stigma and inadvertent disclosure of HIV status were less interested in group models.ConclusionsClients in DART models were very satisfied with their care. HCW were also supportive of the new approach to HIV treatment delivery, noting its advantages to HF, HCW and to clients. Given the heterogeneous needs of people living with HIV, no single DART model will suit every client; a diverse portfolio of DART models is likely the best strategy.

Impact of fast-track care program in laparoscopic rectal cancer surgery: a cohort-comparative study.

Fast-track care programs after surgery improve recovery and decrease the length of hospital stay and postoperative morbidity in colonic cancer. However, the true impact of these programs on morbidity rates after rectal cancer surgery remains unclear. We aimed to assess the feasibility and impact of the fast-track program on postoperative outcomes after restorative laparoscopic rectal cancer resection and temporary loop ileostomy. This single-center observational study assessed data of patients undergoing elective rectal cancer surgery during a defined period before (standard group) and after the introduction of a fast-track program (fast-track group) from a prospectively maintained database. The primary endpoint was postoperative 90-day morbidity. Secondary endpoints were 30-day morbidity, fast-track program compliance, length of hospital stay, and readmission rate. Overall, 336 patients (n = 176, standard group; n = 160, fast-track group) were assessed; there was no significant between-group difference in the patients' baseline characteristics (age, sex, body mass index, comorbidities, or neoadjuvant treatment). The protocol compliance rate was 91.4% in the fast-track group. The 90-day morbidity and mean total length of hospital stay were significantly lower in the fast-track group than in the standard group (34% vs 49%, respectively, p < 0.01 and 8.96days vs 10.2days, p < 0.01, respectively). There was no difference in readmission rates. Multivariate analysis revealed the fast-track program to be the only predictive factor of postoperative morbidity. Fast-track programs can be safely implemented following rectal cancer surgery to reduce the overall morbidity rate and length of hospital stay without adversely increasing the readmission rate.