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Fast-Track Cardiac Anesthesia: A Vital Core of Perioperative Cardiac Surgery Programs
INTRODUCTION
Opioid-based anesthesia emerged as a safe and effective way to maintain hemodynamic stability in patients undergoing cardiac surgery in the early 1970s and used large doses (typically 0.5 mg/kg to 1.0 mg/kg) of long-acting opioids such as morphine. , The limitations of morphine-based cardiac anesthesia included delayed anesthetic emergence, prolonged postoperative mechanical ventilation, and histamine-induced hypotension. In response to these limitations, fentanyl-based anesthesia (typical doses of 50 mcg/kg to 100 mcg/kg) was introduced in the late 1970s and soon became the standard cardiac anesthetic through the 1980s because of its hemodynamic stability and comparatively faster anesthetic emergence. , The titration of short-acting benzodiazepines, such as midazolam, was added in the early 1990s to enhance amnesia, lower the total opioid requirement, and shorten the stay in the intensive care unit (ICU).
As cardiac surgical case volume and associated costs soared, there was a gradual move to facilitate an earlier discharge from the ICU after cardiac surgery. , Fast-track cardiac anesthesia (FTCA) emerged as a streamlining solution with a focus on rapid recovery after cardiac surgery by tailoring the anesthetic plan to facilitate tracheal extubation within 6 hours after cardiac surgery. , The anesthetic options in FTCA have included an expanded role for inhalational anesthesia, the limitation of long-acting opioids, the use of nonnarcotic analgesic adjuncts, and the incorporation of regional anesthetic techniques. The success of FTCA must also include the systematic implementation and entrenchment of early tracheal extubation and accelerated recovery protocols in the ICU.
In recent years, FTCA has remained a vital component for enhanced recovery after cardiac surgery (ERAS – cardiac) protocols worldwide. The ERAS Society has published recommendations for the care of cardiac surgical patients, which are listed in Table 35.1 . , The benefits of FTCA within an ERAS framework include earlier ambulation, lower risk for infection, shorter duration of mechanical ventilation and length of ICU stay, and enhanced patient experience with a more prompt return to home. Furthermore, this approach also benefits cardiac surgical programs through its alignment with the quality measures developed by the Society of Thoracic Surgeons, including outcomes such as prolonged mechanical ventilation and infection. ,
TABLE 35.1
Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations by Recommendation Class and Level of Evidence
| Class 1 Recommendations (Strong Recommendation: Benefit Far Exceeds Risk) | |
|---|---|
| A | Tranexamic acid or epsilon aminocaproic acid for on-pump cardiac surgical procedures |
| B-R | Perioperative glycemic control |
| B-R | A care bundle of evidence-based best practices to reduce surgical site infections |
| B-R | Goal-directed fluid therapy |
| B-NR | Perioperative, multimodal, opioid-sparing pain management protocol |
| B-NR | Avoid postoperative hypothermia (< 36.0°C) |
| B-NR | Maintenance of chest tube patency to prevent retained blood |
| B-NR | Systematic screening for postoperative delirium at least once per nursing shift |
| C-LD | Cease smoking and hazardous alcohol consumption 4 weeks before elective surgery |
| Class IIa Recommendations (Moderate Recommendations: Benefit Much Greater Than Risk) | |
| B-R | Early detection of kidney stress and multimodal interventions to avoid acute kidney injury |
| B-R | Use of rigid sternal fixation to potentially improve or accelerate sternal healing and reduce mediastinal wound complications |
| B-NR | Prehabilitation for patients undergoing elective surgery with multiple comorbidities or significant deconditioning |
| B-NR | An insulin infusion to treat hyperglycemia in all patients postoperatively |
| B-NR | Strategies to ensure tracheal extubation within 6 hours of surgery |
| C-LD | Patient engagement tools, including online/application-based systems to promote educations, compliance, and patient-reported outcomes |
| C-LD | Chemical of mechanical thromboprophylaxis after surgery |
| C-LD | Preoperative measurement of hemoglobin A1c to assist with risk stratification |
| C-LD | Preoperative correction of nutritional deficiency when feasible |
| Class IIb Recommendations (Weak Recommendation: Benefit Greater Than Risk) | |
| C-LD | Continued consumption of clear liquids until 2–4 hours before general anesthesia |
| C-LD | Preoperative oral carbohydrate loading may be considered before surgery |
| Class III (No Benefit) Recommendations | |
| A | Stripping or breaking the sterile field of chest tubes to remove clots |
| Class III Recommendations (No Clinical Benefit – Possibility of Clinical Harm) | |
| B-R | Avoid hyperthermia (>37.9°C) when rewarming on cardiopulmonary bypass |
Levels of Evidence: A – High quality of evidence from multiple randomized trials; B-R – Moderate quality of evidence from randomized studies; B-NR – Moderate quality of evidence from nonrandomized studies; C Limited data.
(Adapted from Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg . 2019;154:755–766.)
The Safety of Fast-Track Cardiac Anesthesia
Since the early 2000s, several large meta-analyses have analyzed the evidence for the safety of FTCA. , The first meta-analysis ( N = 1800; 10 randomized trials) reviewed morbidity and mortality in patients undergoing coronary artery or valve surgery with cardiopulmonary bypass. In this pooled data set, FTCA significantly reduced the mean time to tracheal extubation by 8.1 hours with a trend toward reduced perioperative mortality (1.2% vs. 2.7%; P = .09). Furthermore, FTCA resulted in equivalent rates of major morbidities, such as prolonged ICU stay, stroke, myocardial infarction (MI), major bleeding, sepsis, major wound infection, and renal failure. These findings were confirmed in in an updated Cochrane meta-analysis ( N = 4483; 28 randomized trials). Thus FTCA offers advantages to both the patient and the health system without any concomitant increase in morbidity or mortality, explaining its adoption and entrenchment in contemporary perioperative practice.
An important limitation in FTCA is that clinical trials demonstrating its perioperative safety did not include high-risk patient groups. , Collectively, these trials excluded patients with severe left ventricular systolic dysfunction, advanced lung disease, and advanced age (defined as age older than 70 years). Advanced age is a risk factor for increased mortality and prolonged hospital stay after cardiac surgery. , A randomized FTCA trial showed that elderly patients had significantly prolonged tracheal extubation ( P < .03) and hospital stay ( P < .001). Two further clinical trials ( N = 2065) confirmed that advanced age remains a significant risk factor for prolonged hospital stay after FTCA ( P < .05). , Even in the setting of an FTCA paradigm, advanced age remains a significant independent predictor for delayed tracheal extubation and prolonged ICU stay. In contrast to these earlier clinical trials, a contemporary large retrospective analysis ( N = 38100: 2000–2017) found that, despite increasing age (65.1 +/- 9.9 years to 67.6 +/-10.8 years; P < .001), the duration of mechanical ventilation and ICU and hospital stay steadily decreased over time, although these older patients had a lower burden of comorbidities.
Anesthetic design can offset some of this excessive risk in the elderly after cardiac surgery. In the elderly, a randomized FTCA trial demonstrated that propofol infusion and limitation of benzodiazepine significantly shortened time to tracheal extubation ( P < .02), as well as discharge from the ICU ( P < .02), and hospital ( P < .04). Given the relationship between benzodiazepine exposure and delirium, duration of mechanical ventilation, and length of stay, the limitation of perioperative benzodiazepines is an important concept in contemporary FTCA that future trials will likely examine. ,
The Cost-Effectiveness of Fast-Track Cardiac Anesthesia
Given that FTCA is safe, a thorough evaluation of its cost-effectiveness becomes relevant. The costs of a cardiac surgical procedure are determined by operating room time, perioperative complications, and length of stay. , A randomized trial ( N = 100) demonstrated that FTCA reduced total costs per case by 25%. These significant savings were predominantly in reduced nursing and ICU costs without increasing perioperative complications. A subsequent analysis by the same investigators demonstrated that FTCA significantly decreased resource utilization in the first year after cardiac surgery.
The cost-effectiveness of FTCA depends on the implementation of a fast-track recovery protocol in and beyond the ICU. The incorporation of FTCA is an essential component of a cost-effective fast-track recovery model. The reduction of ICU stay in FTCA is also dependent on an efficient hospital staffing model and smooth discharge procedures. These care processes require multidisciplinary collaboration and effective communication that are the basis for the recommendations in the recent multisociety guidelines ( Tables 35.2 and 35.3 ; see also Table 35.1 ). , ,
TABLE 35.2
Class I Recommendations for Anesthetic Considerations in CABG Surgery
| Recommendation | Level of Evidence |
|---|---|
| Anesthetic management for early postoperative tracheal extubation and accelerated recovery of appropriate patients undergoing uncomplicated CABG is recommended. | Level B |
| Multidisciplinary measures should ensure an optimal analgesia and patient comfort throughout the perioperative period. | Level B |
| Efforts are recommended to improve interdisciplinary communication and safety in the perioperative environment (e.g., formalized checklists for multidisciplinary communication). | Level B |
| A fellowship-trained anesthesiologist (or experienced board-certified practitioner) credentialed in perioperative transesophageal echocardiography is recommended to provide or supervise anesthetic care of high-risk patients. | Level C |
Levels of Evidence: B – Moderate quality of evidence; C Limited data, including expert opinion.
CABG , Coronary artery bypass grafting.
(Adapted from Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:2610–2642).
TABLE 35.3
Class II & III Recommendations for Anesthetic Considerations in CABG Surgery
| Recommendation | Class and Evidence |
|---|---|
| Volatile anesthetic-based regimens may facilitate early tracheal extubation and reduce patient recall. | IIa (Level A) |
| The effectiveness of high thoracic epidural anesthesia/analgesia for routine analgesic use is uncertain. | IIb (Level B) |
| Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG. | III (Level B) |
| Routine early tracheal extubation strategies in facilities with limited resources for airway emergencies or advanced respiratory support is potentially harmful. | III (Level C) |
Class IIa recommendation: Benefit much greater than risk. Class II b recommendation: Benefit greater than risk. Class III recommendation: No clinical benefit with potential for clinical harm. Levels of Evidence: A – High quality of evidence; B – Moderate quality of evidence; C - Limited data, including expert opinion.
CABG , Coronary artery bypass grafting.
(Adapted from Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:2610–2642.)
The maturation of minimally invasive valve surgery and transcatheter valve interventions have resulted in equivalent or better outcomes compared with conventional techniques, in addition to reduced costs and resource consumption. This paradigm shift in cardiac surgery will continue to result in significant advances in cost-effectiveness and value.
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