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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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
Predictors of failure1
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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
Aims
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We sought to determine if there was
any difference in postoperative
management and complication rates
between patients who were fasttracked and those who were not
Methods
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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’
Fast Track Criteria
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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
Definite exclusions
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Not meeting above criteria
Mitral valve replacement
‘Redo’ valve operations
Previous history of CVA
Swan-Ganz catheter
Infoflex and case note
review
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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
Results
Age:
Group
Destination
Mean (yrs)
SD
CABG
CICU
62.4
6.004
PCU
65.5
6.899 0.228
CICU
62.8
12.19
PCU
63.5
11.84 0.897
AVR
p
Logistic EUROscore:
Group
Destination
Mean
SD
CABG
CICU
2.17
1.572
PCU
2.41
1.212
CICU
4.01
3.163
PCU
4.22
2.798
AVR
p
0.699
0.874
AVR
Time to extubation
PCU
CABG
CICU
PCU
CICU
0
2
4
Mean time to extubation (hrs)
6
Group
Destination
Mean (hrs)
SD
AVR
PCU
2.261
1.320
CICU
5.841
2.114
PCU
3.093
2.067
CICU
5.657
4.170
CABG
p
0.00003
0.02
Volume of fluid in 1st 12 hrs
AVR
PCU
CABG
CICU
PCU
CICU
0
1
2
3
4
5
Volume of fluids in 1st 12 hours (L)
Group
Destination
Mean (L)
SD
AVR
PCU
2.764
0.527
CICU
3.336
0.584
PCU
2.951
0.932
CICU
4.002
0.660
CABG
p
0.018
0.006
Units of red cells given postoperatively
AVR
PCU
CICU
CABG
PCU
CICU
0
0.2
0.4
0.6
0.8
Red cells given (units)
1
1.2
Group
Destination
Mean (units)
SD
AVR
PCU
0.2
0.632
CICU
0.7
1.159
PCU
0.4
0.516
CICU
1.2
1.475
CABG
p
0.15
0.07
Noradrenaline useage
AVR
PCU
CABG
CICU
PCU
CICU
0%
10%
20%
30%
40%
50%
60%
70%
Noradrenaline
Group
Destination
Noradrenaline
AVR
PCU
10%
CICU
10%
PCU
20%
CICU
70%
CABG
Time until central line removed
AVR
PCU
CICU
CABG
PCU
CICU
0
1
2
Time (days)
3
4
Group
Destination
Mean (days)
SD
AVR
PCU
2.5
0.707
CICU
2.1
0.568
PCU
2.1
0.568
CICU
3.5
1.510
CABG
P
0.18
0.013
Time until arterial line removed
AVR
PCU
CICU
CABG
PCU
CICU
0
0.5
1
1.5
Time (days)
2
2.5
3
Group
Destination
Mean (days)
SD
AVR
PCU
1.9
0.876
CICU
1.3
0.483
PCU
1.4
0.516
CICU
2.9
1.595
CABG
p
0.07
0.011
Time spent in a critical care environment
AVR
PCU
CICU
CABG
PCU
CICU
0
1
2
Time (days)
3
4
Group
Destination
Mean (days)
SD
AVR
PCU
2.2
1.135
CICU
1.8
0.789
PCU
1.6
0.699
CICU
3.7
0.699
CABG
P
0.372
0.004
Respiratory complications
30
20
10
0
CICU
PCU
CABG
CICU
PCU
AVR
% respiratory complications
Group
Destination
% respiratory
complications
CABG
CICU
30
PCU
0
CICU
10
PCU
0
AVR
Discussion
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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
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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 early and late mortality3-5
Inotrope usage is also associated with
increased hospital stay and mortality6
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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
Conclusion
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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
Changes since this study
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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
Limitations
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Small study population
Limited fast track criteria
References
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•
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Starr, Norman J. MD Perioperative determinants of morbidity and mortality in
elderly patients undergoing cardiac surgery Critical Care Medicine:September
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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
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