Fast-track Recovery Protocol Research Articles

Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer

Fast-track (FT) recovery protocols have demonstrated advantages over historical recovery routines after open colectomy; however, their impact in recovery after laparoscopic colectomy is not clearly defined. This study was designed to determine whether patients who recover on FT protocol after laparoscopic colectomy have a shorter length of stay (LOS) and fewer complications compared with patients who recover on standard (non-FT) protocol. A cohort of consecutive patients with colon cancer who underwent completed laparoscopic-assisted right hemicolectomy from 2005-2007 was identified. Univariate and multivariate logistic analyses were performed to identify risk factors for increased LOS and postoperative complications with recovery protocol as the primary predictor. A total of 197 patients were included: 115 (58%) patients recovered on a non-FT protocol, and 82 (42%) patients on FT protocol. Univariate analysis showed no differences with respect to age, gender, body mass index, or American Society of Anesthesiologists (ASA) class between groups. The median (interquartile range) LOS was 4 (range, 3-6) days and 3 (range, 3-4) days for the non-FT and FT recovery patients, respectively (p < 0.001). On multivariate analysis, independent risk factors for increased LOS were complications (p < 0.001) and non-FT recovery (p = 0.007). Non-FT recovery also was associated with increased complications (56 vs. 29%, p = 0.0002); this remained significant on multivariate analysis (p < 0.001). Readmissions were similar (p = 1.0) between recovery groups. No mortalities were observed at 30 days. Fast-track recovery is independently associated with a shorter LOS and decreased morbidity after laparoscopic right hemicolectomy.

Feasibility of the fast-track recovery program after cardiac surgery in Japan

The purpose of this study was to determine if a fast-track recovery protocol that is applied in other countries can be used in the present Japanese medical system. Second, we wanted to evaluate the differences if the protocol was adapted from the viewpoint of cost saving, postoperative hospital stay, and adverse complications. We retrospectively analyzed 94 consecutive patients who underwent cardiovascular surgery with conventional techniques on cardiac arrest requiring cardiopulmonary bypass between July 1, 2004 and June 30, 2006. We started our fast-track recovery protocol from July 1, 2005. We compared the results of the conventional group (before July 1, 2005) and the fast-track recovery protocol group (after July 1, 2005). Moreover, we used a unique questionnaire and investigated how the patients in the fast-track group felt about the short hospital stay postoperatively. The mean postoperative hospital stay was 36.7 +/- 6.0 days for the conventional group and 15.0 +/- 12.4 days for the fast-track group, with a statistically significant difference (P = 0.01). The mean cost fell by almost half, from 712545 yen to 383268 yen (P = 0.038). The difference in complication rates was not statistically significant. A fast-track recovery protocol can be safely adapted to patients in the Japanese system without increasing the mortality or morbidity rate. Based on our unique questionnaires, the most important factor was sufficient and repeated explanations preoperatively to the patients and their family members. Second, good pain control with routine use of acetaminophen and sporadic morphine orally has a great effect on the patients' recovery.

Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol

The development of less invasive methods for myocardial revascularization such as "off-pump" cardiac surgery, and new methods of anesthesia and postoperative care protocols such as "fast-track recovery" (FTRC), have contributed to a significant reduction in postoperative intensive care unit (ICU) and hospital length of stay after cardiac surgical procedures. The objectives of this study were to identify perioperative risk factors of prolonged hospital stay, hospital mortality, and readmission rates in off-pump coronary artery bypass surgery (CABG) patients undergoing the FTRC protocol. Eighty consecutive patients undergoing off-pump coronary artery bypass surgery with FTRC protocol were included in the study. For the first purpose of this protocol, early extubation is defined as removal of the endotracheal tube within 6 h of arrival at the surgical ICU. The second purpose was to obtain a minimal length of stay in the ICU (<24 h) and hospital discharge within 5 days. We analyzed the influence of the preoperative, intraoperative, and postoperative variables on prolonged hospital stay, hospital mortality, and hospital readmission. Three patients died during hospitalization, giving a hospital mortality rate of 3.75%. The causes of hospital death were massive stroke and sepsis. Using multivariate logistic regression analysis, hypertension (P = 0.0185), postoperative stroke (P = 0.0001), and sternal infection (P = 0.0007) were identified as independent predictors of hospital mortality. Mean hospital length of stay was 4.23 +/- 0.75 days. Univariate and multivariate logistic regression analysis revealed that postoperative blood use (P = 0.0095) was the major independent predictor of prolonged hospital stay. During the 30-day observation period, seven patients were readmitted. One of these patients died on postoperative day 45 from mediastinitis and sepsis. Multivariate logistic regression analysis identified age (P = 0.0033) and hypertension (P = 0.045) as independent predictors of hospital readmission. FTRC protocols can be performed safely in patients with off-pump CABG, and the mortality and readmission rates following this protocol were found to be within acceptable ranges.

Fast-Track Recovery in Noncoronary Cardiac Surgery Patients

Fast-track recovery protocols result in shorter hospital stays and decreased costs in coronary artery bypass grafting (CABG) surgery. However, data based on an objective scoring system are lacking for the impact of these protocols on patients undergoing cardiac surgery other than isolated CABG. Between March 1999 and March 2003, 299 consecutive patients who underwent open cardiac surgery other than isolated CABG were analyzed to evaluate the safety and efficacy of fast-track recovery. The parameters evaluated as predictors of mortality, ie, delayed extubation (>360 minutes), intensive care unit (ICU) discharge (>24 hours), increased length of hospital stay (>5 days), and red blood cell transfusion, were determined by regression analysis. Standard perioperative data were collected prospectively for every patient. Seventy-two percent of the patients were extubated within 6 hours, 87% were discharged from the ICU within 24 hours, and 60% were discharged from the hospital within 5 days. No red blood cells were transfused in 67% of the patients. There were no predictors of mortality. The predictors of delayed extubation were preoperative congestive heart failure (P = .005; odds ratio [OR], 4.5; 95% confidence interval [CI], 1.6-12.6) and peripheral vascular disease (P = .02; OR, 6; 95% CI, 1.9-19.4). Factors leading to increased ICU stay were diabetes (P = .05; OR, 3.6; 95% CI, 1-12.6), emergent operation (P = .04; OR, 6.1; 95% CI, 1.1-33.2), red blood cell transfusion (P = .03; OR, 2.9; 95% CI, 1.1-7.8), chest tube drainage >1000 mL (P = .03; OR, 3.4; 95% CI, 1.1-10.2). The predictors of increased length of hospital stay were ICU stay >24 hours (P = .001; OR, 5.9; 95% CI, 2-17), EuroSCORE >5 (P = .05; OR, 1.8; 95% CI, 1-3.2), and chronic obstructive pulmonary disease (P = .003; OR, 3.7; 95% CI, 1.5-8.7). Predictive factors for transfusion of red blood cells were diabetes (P = .04; OR, 2.9; 95% CI, 1.1-8.1), delayed extubation (P = .02; OR, 2.7; 95% CI, 1.4-5.1), increased ICU stay (P = .04; OR, 2.6; 95% CI, 1-6.4), and chest tube drainage >1000 mL (P = .001; OR, 4.3; 95% CI, 2-9.3). This study confirms the safety and efficacy of the fast-track recovery protocol in patients undergoing open cardiac surgery other than isolated CABG.

Redução do período de internação e de despesas no atendimento de portadores de cardiopatias congênitas submetidos à intervenção cirúrgica cardíaca no protocolo da via rápida

To assess the care provided to patients with congenital heart diseases and ischemic heart diseases undergoing cardiac surgery according to the fast-track recovery protocol compared with those undergoing the conventional procedure. The transfer of patients from one hospital unit to another was assessed for 175 patients, 107 (61%) men and 68 (39%) women, with ages ranging from 0.3 to 81 years. The discharge rate from the different hospital units per unit of time of the patients with congenital heart diseases treated according to the fast-track recovery protocol compared with that of patients conventionally treated was as follows: a) 11.3 times faster than the discharge rate of patients treated according to the conventional protocol, in regard to the time spent in the operating room; b) 6.3 times faster in regard to the duration of the surgical intervention; c) 6.8 times faster in regard to the duration of anesthesia; d) 1.5 times faster in regard to the duration of perfusion; e) 2.8 times faster in regard to the stay in the postoperative recovery I unit; f) 6.7 times faster in regard to hospital stay (time period between hospital admission and hospital discharge); g) 2.8 times faster in regard to the stay in the preoperative unit; h) 2.1 times faster in regard to the stay in the admission unit after discharge from postoperative recovery; i) associated with reduced costs. The difference was not significant for patients with ischemic heart disease. A reduction in the length of hospital stay and costs for the care of patients undergoing cardiac surgery according to the fast-track protocol was observed.

Re-admission and mortality rate after a fast-track recovery protocol in off-pump coronary artery bypass surgery patients

*Departments of Cardiovascular Surgery and Anaesthesiology, Gaziantep University, Faculty of Medicine, Gaziantep, Turkey

Fast-track Cardiac Surgery in Children: Feasibility in Bangladeshi Setting

Background: Fast-track recovery protocols in cardiac surgery is gaining worldwide popularity and have contributed to significant reductions in the postoperative hospital stay and cost without any increase in postoperative mortality and morbidity. The aim of this study was to find out the feasibility of fast track paediatric cardiac surgery in Bangladeshi setting. Method: It was a prospective study conducted in National Institute of Cardio-vascular Diseases, Dhaka, from July 2009 to June 2010. All patients, between 3 to 18 years, underwent surgical closure of atrial or ventricular septal defect under cardio-pulmonary bypass. 20 patients from our unit served as fast track group and 30 patients from other units of the same hospital served as conventional group. Fast track patients were extubated in less than 6 hours after surgery, shifted from ICU in less than 24 hours and geared up to discharge home within 3 days of surgery. Result: 18 (90%) of the 20 patient of the fast track group were discharged within 3 days of surgery, 2 patients cannot be discharged within this time frame. Mean post operative hospital stay for study group was 3.1 days, whereas the mean hospital stay in the control group was 7.5 days. Follow-up was 100% complete at 30 days. There was no major in-hospital or out-of-hospital complications in either group. No patient was readmitted at our centre or elsewhere for any complication arising from this process. Conclusion: Fast tracking is feasible and safe in low-risk paediatric open-heart surgery in Bangladeshi scenario. A multidisciplinary approach with a set protocol is required to achieve this goal in a safe and reproducible manner. Keywords: Cardiac surgery; Congenital heart disease; Fast track; Hospital discharge. DOI: 10.3329/cardio.v3i1.6427Cardiovasc. j. 2010; 3(1): 50-54