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THE IMPACT OF THE POSTOPERATIVE ‘FAST-TRACK’ PROTOCOL ON PATIENT MANAGEMENT AND OUTCOMES

THE IMPACT OF THE POSTOPERATIVE ‘FAST-TRACK’ PROTOCOL ON PATIENT MANAGEMENT AND OUTCOMES. A Sharkey, P Braidley, N Briffa, G Cooper, S Forlani, D Hopkinson, T Locke, P Sarkar, G Wilkinson, G Chetty Northern General Hospital, Sheffield. Introduction.

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THE IMPACT OF THE POSTOPERATIVE ‘FAST-TRACK’ PROTOCOL ON PATIENT MANAGEMENT AND OUTCOMES

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  1. THE IMPACT OF THE POSTOPERATIVE ‘FAST-TRACK’ PROTOCOL ON PATIENT MANAGEMENT AND OUTCOMES A Sharkey, P Braidley, N Briffa, G Cooper, S Forlani, D Hopkinson, T Locke, P Sarkar, G Wilkinson, G Chetty Northern General Hospital, Sheffield

  2. Introduction A stay on the intensive care unit (ICU) is a significant component of the cost of cardiac surgery Move towards ‘fast-tracking’ patients Early extubation and management on a high dependency unit

  3. Predictors of failure1 • Impaired left ventricular function with or without recent acute coronary syndrome • ‘Re-do’ operation • Extracardiac arteriopathy • Preoperative intra-aortic balloon pump • Raised serum creatinine • Nonelective and complex surgery

  4. Aims We sought to determine if there was any difference in postoperative management and complication rates between patients who were fast-tracked and those who were not

  5. Methods Two groups: CABG x3 + AVR 6 month period PCU and CICU admissions books reviewed 10 consecutive fast-tracked patients for each group Fast-track criteria examined Info-flex database used to determine 10 consecutive cases sent to CICU that were ‘fast-trackable’

  6. Fast Track Criteria Age 75yrs or less Moderate to good LV function Creatinine <125 Diabetes only if well controlled Into recovery before 1430 No unresolved intra-operative event Apparent adequate haemostasis

  7. Definite exclusions Not meeting above criteria Mitral valve replacement ‘Redo’ valve operations Previous history of CVA Swan-Ganz catheter

  8. Infoflex and case note review • Patient demographics • Euroscore • Bypass and cross clamp times • Time to extubation • Volume of fluids given in 1st 12 hours • Blood products given • Inotrope useage • Date of removal of lines • Date of removal of urinary catheter • Number of days before return to the ward • Post-operative complications

  9. Results Age: Logistic EUROscore:

  10. Time to extubation

  11. Volume of fluid in 1st 12 hrs

  12. Units of red cells given postoperatively

  13. Noradrenaline useage

  14. Time until central line removed

  15. Time until arterial line removed

  16. Time spent in a critical care environment

  17. Respiratory complications

  18. Discussion No significant difference in the pre-operative condition or the co-morbidities of the patients Most of the differences found were in the CABG group In both groups, those sent to CICU had a longer time to extubation Early extubation reduces length of stay in both high dependancy units and overall hospital stay2

  19. Early extubation has a lower re-intubation rate2 Much larger volume of IV fluids given in the 1st 12 hours in the CICU groups A significantly higher number of units of red cells given to the CABG patients in CICU Red blood cell transfusions associated with a greater risk of infection, ischemic postoperative morbidity, hospital stay and increased earlyand late mortality3-5 Inotrope usage is also associated with increased hospital stay and mortality6

  20. Prolonged length of time CVP lines are left in situ increases the risk of sepsis Associated with multi-organ disfunction, prolonged ITU stay and in hospital mortality7,8 Less time spent in a critical care environment by those fast tracked No respiratory complications in those fast tracked ?due to early extubation Early ambulation associated with early extubation and transfer to ward environment – less DVT/PE

  21. Conclusion • A fast track approach has been found to be feasible and beneficial in numerous studies, including ours • All patients who are ‘fast-trackable’ should be fast-tracked whenever feasible • Time pressures in recovery should not preclude patients from being fast-tracked • If fast-tracking is not possible, fast-track protocols should be employed on CICU

  22. Changes since this study • Fast-track criteria modified • Older patients • Higher creatinine • Poor LV function • A fast-track approach has been proven to be appropriate in patients over 709

  23. Limitations • Small study population • Limited fast track criteria

  24. References • Constantinides VA, Tekkis PP, Fazil A, Kaur K, Leonard R, Platt M, Casula R, Stanbridge R, Darzi A, Athanasiou T. Fast-track failure after cardiac surgery: development of a prediction model. Crit Care Med. 2006 Dec;34(12):2875-82 • Dmitri Chamchad MD, ‡, Jay C. Horrow MD, MS‡, , , Lev Nachamchik MSc, Francis P. Sutter DO†, Louis E. Samuels MD†, ‡, Candace L. Trace RN, BA†, Francis Ferdinand MD† and Scott M. Goldman MD. The Impact of Immediate Extubation in the Operating Room After Cardiac Surgery on Intensive Care and Hospital Lengths of Stay. J Cardiothorac Vasc Anesth. 2010 Jul 21 • Murphy PJ, Connery C, Hicks GL, Jr, Blumberg N. Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations. J Thorac Cardiovasc Surg. 1992 Oct;104(4):1092–1099 • Collins JD, Bassendine MF, Codd AA, Collins A, Ferner RE, James OF. Prospective study of post-transfusion hepatitis after cardiac surgery in a British centre. Br Med J (Clin Res Ed). 1983 Nov 12;287(6403):1422–1424 • Gavin J. Murphy, BSc, ChB, MD, FRCS(CTh); Barnaby C. Reeves, BA, MSc, DPhil; Chris A. Rogers, BSc, PhD; Syed I.A. Rizvi, MBBCh, MRCS; Lucy Culliford, BSc, MSc, PhD; Gianni D. Angelini, MCh, MD, FRCS, FETCS. Increased Mortality, Postoperative Morbidity, and Cost After Red Blood Cell Transfusion in Patients Having Cardiac Surgery.Circulation. 2007;116:2544-2552.

  25. References (cont) • Rady, Mohamed Y. MD, PhD, FRCS, MRCP; Ryan, Thomas MB, MRCPI, FFARCSI; Starr, Norman J. MD Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery Critical Care Medicine:September 2001;29:S163-S172 • Serkan Öncü,1 Halit Özsüt,2 Ayşe Yildirim,3 Pinar Ay,4 Nahit Çakar,3 Haluk Eraksoy,2 and Semra Çalangu2. Central venous catheter related infections: Risk factors and the effect of glycopeptide antibiotics. Ann Clin Microbiol Antimicrob. 2003; 2: 3 • Marin H. Kollef, Linda Sharpless, Jon Vlasnik, Christina Pasque, Denise Murphy, and Victoria J. Fraser The Impact of Nosocomial Infections on Patient Outcomes Following Cardiac Surgery CHEST September 1997 vol. 112 no. 3 666-675 • Kogan A, Ghosh P, Preisman S, Tager S, Sternik L, Lavee J, Kasiff I, Raanani E. Risk factors for failed "fast-tracking" after cardiac surgery in patients older than 70 years J Cardiothorac Vasc Anesth. 2008 Aug;22(4):530-5

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