Fast track cardiac patients: myth or reality?

D. L. REICH, M.D.

There is no question that fast track cardiac anesthesia is a reality in North American and European medical practice. The economics of global pricing and managed care have forced clinicians to reexamine and change their practice patterns in order to remain competitive or simply function more efficiently in an area of limited resources. Rapid extubation following cardiac surgery is not a new concept [1], but was considered unwise by many clinicians until quite recently based upon several concerns. For example, Mangano et al. demonstrated in 1992 that patients receiving intensive sufentanil analgesia postoperatively had a lower incidence and severity of postoperative myocardial ischemia [2]. Other potential concerns included ventilatory dysfunction and long-term outcomes such as myocardial infarction and mortality rates. A number of recently published articles on this topic has forced a reexamination of the concerns traditionally applied to early extubation following cardiac surgery. The preponderance of these articles clearly demonstrate a beneficial or at least neutral effect of the early extubation protocol on the various process and outcome variables analyzed. The following is a brief review of the more pertinent recent publications. Cheng et al. examined costs and resource utilization in 100 patients randomly assigned to early or late extubation after CABG surgery [3]. Including all costs of complications, intensive care unit costs were decreased by 53% (p<0.026) and total CABG surgery cost by 25% (p<0.019) in early extubation patients. Additionally, the cost savings in intensive care unit nursing and supplies was 23% (p<0.005), in ward nursing and supplies was 11% (p<0.05), and in respiratory therapy was 12% (p<0.05). The total cost savings per patient having CABG was 9% (p<0.001). In this Canadian institution, the
Correspondence to: Associate Professor of Anesthesiology, The Mount Sinai Medical Center, New York, NY.

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number of intensive care bed is limited. In this setting, therefore, early extubation also reduced elective case cancellations (p<0.002). There was no increase in the number of postoperative complications in this small cohort. The same group [4] also performed an analysis of cardiac and respiratory morbidity which they defined as postoperative myocardial ischemia, postoperative myocardial infarction, and perioperative sympathoadrenal stress response, postextubation apnea, alveolar-arterial oxygen gradient, pulmonary shunt fraction, oxygen consumption, atelectasis, and reintubation rates. They also noted hemodynamic values and vasoactive medication requirements, intraoperative awareness, postoperative cognitive function, 30 day mortality, and intensive care unit and hospital lengths of stay. Postoperative extubation time and intensive care unit and hospital lengths of stay were significantly shorter in the early group. At 48 hours after operation, there were no significant differences between the two groups in myocardial ischemia incidences, ischemia burdens, or creatine kinase isoenzyme MB levels. No patients had postoperative myocardial infarction in the early extubation group. Intrapulmonary shunt fraction improved significantly in the early group at 4 hours after extubation. They concluded that early extubation after coronary artery bypass grafting is safe and does not increase perioperative morbidity. A group from Cleveland [5] also performed a systematic analysis of economic benefits using cost-based rather than charge-based calculations in a consecutive series of 690 patients undergoing coronary bypass surgery. They studied a group of patients (n = 362) who underwent coronary bypass surgery in 1995, and compared them with a historical control group (n = 328) of patients operated on during 1994. Baseline characteristics such as age, gender, previous myocardial infarctions, ejection fraction, reoperations, diabetes, and left main stenosis were similar in both groups. Operative mortality (3.3%) did not differ between the two groups and the incidence of serious morbidity was 10.9%. Postoperative length of stay declined from 9.4 days to 7.7 days (p<0.01), which is long compared with other studies. This was accompanied by a significant (p = 0.001) reduction in variable direct cost per case. Another study [6] from Minneapolis examined predictors and costeffectiveness of early extubation after coronary artery bypass grafting in 645 patients. Patients were divided into three groups: those extubated in <12 hours (7.55 +/- 2.5 hours, 269 patients), those extubated in 12-24 hours (16.85 +/- 3.3 hours, 291 patients); and any patient extubated after 12 hours (376 patients). The overall reintubation rate was less than 1%. Stepwise logistic regression analyses revealed that older patients, female sex, use of preoperative diuretics and unstable angina were independent predictors of late extubation. They also noted decreased postoperative length of stay, reduction of cost and resource utilization, and lower hospital charge per patient (approximately $6,000 less) in the early extubation patients. Habib et al. [7] also examined the factors that may influence early extubation in a retrospective study of 507 patients. They assessed the role of 48 variables in determining the period of ventilatory support. Logistic and linear multivariate regression analyses implicated increased age, New York Heart Association functional class IV, intraoperative fluid retention, postoperative intraaortic balloon pump requirement, and bank blood transfusions as

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predictors of late extubation. Also, the linear regression linked lower body weight and number of anastomoses (or grafts) to increased mechanical ventilatory support. They concluded that earlier extubation may be achieved by actively reducing fluid retention (e.g., by hemoconcentration) and time on bypass (e.g., normothermia), although it is questionable whether such statements are justified based on retrospective data. A group from Spain [8] performed a prospective, randomized controlled trial of early versus late extubation in 404 consecutive patients. They recorded the type and severity of the disease, surgical risk, type of operation, operative events, postoperative complications, duration of mechanical ventilation, intubation and ICU stay, bleeding, reoperation, vasoactive drugs, and mortality. The median ICU stay was 27 h in group A and 44 h in group B (p = 0.008). Discharge from ICU within the first 24 h postoperatively was 44.3% in group A and 30.5% in group B (p = 0.006). There was no significant difference in complications between groups. Cost-containment is one of the key principles underlying early extubation. In a study from New York, this was analyzed extensively [9]. A multidisciplinary project was undertaken to develop critical pathways for open-heart surgery to help reduce cost, shorten hospital length of stay, and streamline patient care. Prospective data collected on consecutive patients (n = 114) over a 6-months period were compared with retrospective data (n = 382) in elective coronary artery bypass grafting patients. The critical pathway had a significantly shorter total hospital length of stay (7.7+/-2.3 days vs 11.1+/-6 days, p<0.0001) and shorter intensive care unit length of stay (1.5+/-0.9 days vs 2.0+/-2.8 days, p<0.0001). Direct costs were computed by use of hospital charges multiplied by the Medicare cost-to-charge ratio. Mean hospital direct cost (ancillary resources) was $1181 lower in the critical pathway group when compared with the control group (p<0.0001). The postoperative mortality and readmission rates were similar for the two groups. Respiratory function is another variable that has been examined in early extubation patients. Johnson et al. [10] used a matched retrospective cohort design to compare 31 early extubation patients with 112 matched control patients. The matching was based on forced vital capacity, age, and gender. The increase in atelectasis score compared with preoperative (0 = no atelectasis, 4 = lobar collapse) was higher (p<0.01) on the day of extubation in the late extubation group (4.1+/-1.4) compared with the early extubation group (2.6+/-1.3). These findings were not related to pain, which was equivalent between groups. The decreases in spirometry on postoperative day 5 were greater in the late extubation group. Positive fluid balance until extubation was greater in the late extubation group. In this small study, it appeared that early extubation improved respiratory function. Some have suggested that elderly patients may not be appropriate for early extubation. Ott et al. [11] examined this issue in 152 consecutive younger patients (< 70 years) and 167 consecutive elderly patients (>70 years) who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass. There were no statistically significant differences in the 30-day mortality rates or postoperative complications between the elderly and younger patient groups. Rapid recovery with discharge before the fifth postoperative

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day was achieved in 19% of the elderly, in comparison with 48% of the younger patients (p < 0.001). They concluded that although the younger patients had a significantly shorter postoperative length of hospital stay, older patients performed well and are suitable candidates for rapid recovery protocols. In conclusion, the articles cited above regarding early extubation have all been published quite recently [3-11]. There is no major study in this area in which the data suggest deleterious consequences of early extubation following cardiac surgery. While there are certainly patients who cannot enter these early extubation protocols, the vast majority of patients clearly suffer no ill effects and the economic advantages are dramatic. It is even possible that ventilatory function may be improved by this approach [4, 10]. The overwhelming conclusion that is evident from this review of the literature is that early extubation following cardiac surgery is not only feasible and economically viable, but that is probably desirable for most cardiac surgical patients. REFERENCES
[1] Klineberg P.L., Geer R.T., Hirsh R.A., Aukburg S.J. - Early extubation after coronary artery bypass graft surgery. Crit. Care Med., 1977, 5, 272-274. [2] Mangano D.T., Siliciano D., Hollenberg M., Leung J.M., Browner W.S., Goehner P., Merrick S., Verrier E. - Postoperative myocardial ischemia. Therapeutic trials using intensive analgesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology, 1992, 76, 342-353. [3] Cheng D.C., Karski J., Peniston C., Raveendran G., Asokumar B., Carroll J., David T., Sandler A. - Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial. Anesthesiology, 1996, 85, 1300-1310. [4] Cheng D.C., Karski J., Peniston C., Asokumar B., Raveendran G., Carroll J., Nierenberg H., Roger S., Mickle D., Tong J., Zelovitsky J., David T., Sandler A. - Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J. Thorac. Cardiovasc. Surg., 1996, 112, 755-764. [5] Lee J.H., Kim K.H., van Heeckeren D.W., Murrell H.K., Cmolik B.L., Graber R., Effron B., Geha A.S. - Cost analysis of early extubation after coronary bypass surgery. Surgery, 1996, 120, 611-617. [6] Arom K.V., Emery R.W., Petersen R.J., Schwartz M. - Cost-effectiveness and predictors of early extubation. Ann. Thorac. Surg., 1995, 60, 127-132. [7] Habib R.H., Zacharias A., Engoren M. - Determinants of prolonged mechanical ventilation after coronary artery bypass grafting. Ann. Thorac. Surg., 1996, 62, 1164-1171. [8] Reyes A., Vega G., Blancas R., Morato B., Moreno J.L., Torrecilla C., Cereijo E. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. Chest, 1997, 112, 193-201. [9] Velasco F.T., Ko W., Rosengart T., Altorki N., Lang S., Gold J.P., Krieger K.H., Isom O.W. - Cost containment in cardiac surgery: results with a critical pathway for coronary bypass surgery at the New York Hospital-Cornell Medical Center. Best Pract. Benchmarking Healthc., 1996, 1, 21-28.

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[10] Johnson D., Thomson D., Mycyk T., Burbridge B., Mayers I. - Respiratory outcomes with early extubation after coronary artery bypass surgery. J. Cardiothorac. Vasc. Anesth., 1997, 11, 474-480. [11] Ott R.A., Gutfinger D.E., Miller M.P., Alimadadian H., Tanner T.M. - Rapid recovery after coronary artery bypass grafting: is the elderly patient eligible? Ann. Thorac. Surg., 1997, 63, 634-639.

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