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Ann Thorac Surg 1997;64:478-481
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Coronary Artery Bypass Grafting "On Pump": Role of Three-Day Discharge

Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange, California

Accepted for publication March 9, 1997.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. A new emphasis has been directed toward "off-pump" coronary artery bypass grafting to avoid the morbidity of cardiopulmonary bypass and further reduce the postoperative hospital length of stay. With the intent of achieving a hospital discharge for "on-pump" coronary artery bypass grafting procedures comparable with the same procedures "off pump," we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day.

Methods. The cases of 104 consecutive patients who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass were retrospectively reviewed. A rapid-recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthesia protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early extubation as well as a mild state of negative fluid balance and to ensure absence of postoperative bleeding and a safe transfer from the intensive care unit to a monitored floor. On the second postoperative day, chest drains were discontinued, and aggressive ambulation therapy was instituted. If at 72 hours postoperatively the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge home was planned.

Results. The 30-day mortality rate for the entire group was 1.9%. The average postoperative hospital length of stay for the entire series was 4.8 ± 2.4 days. Of the 102 survivors, 30 patients (29%) were discharged within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Patients in group 1 were younger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of an intraaortic balloon pump preoperatively (13% versus 35%). Group 1 patients also had almost no complications and a lower readmission rate (3.3% versus 6.9%).

Conclusions. With the application of a rapid-recovery protocol to patients undergoing "on-pump" coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe for patients who have minimal comorbid conditions.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 481.

The recent transition of the health care industry has had a substantial impact on the practice of cardiovascular surgery [1]. Through innovative perioperative techniques [2, 3] and accelerated recovery protocols [4, 5], predictable outcomes have now been coupled with significant decreases in postoperative length of hospitalization. Recently, we [6] reported the results of such a protocol in an unselected series of patients undergoing isolated coronary artery bypass grafting (CABG). These results as well as those achieved by others [5] demonstrate that rapid-recovery protocols can benefit all patients regardless of age and comorbid conditions.

Despite these developments, a new emphasis has been directed toward "off-pump" CABG to avoid the morbidity of cardiopulmonary bypass (CPB) [7–11] and further reduce the postoperative hospital length of stay (LOS). Although the potential for this approach is attractive, overwhelming acceptance may be limited by surgeons' unwillingness to adopt the techniques of beating heart surgery. In addition, arguments about incomplete revascularization, inadequate referral of single- and double-vessel disease, and dependence on combined surgical and interventional techniques to achieve revascularization goals remain deterrents [12].

We believe that CABG "on-pump" can achieve full revascularization with hospital discharge comparable with "off-pump" CABG. To test this hypothesis, we applied our rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day. Factors common to these patients were then identified and are described here.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From January through September 1996, 104 consecutive patients underwent isolated CABG using CPB. Their cases were retrospectively reviewed. Procedures were performed within 24 hours of cardiac catheterization unless additional time was needed to optimize the clinical condition. Patients who required an urgent operation because of percutaneous transluminal coronary angioplasty, an emergency redo procedure; critical left main stenosis (70%), substantial left ventricular dysfunction (ejection fraction 0.40), or unstable angina refractory to medical therapy received an intraaortic balloon pump preoperatively.

A previously described rapid-recovery protocol [4, 6] that emphasizes short CPB time, early extubation, perioperative steroid and thyroid administration, and aggressive diuresis was applied to all patients. Attention was directed toward reducing CPB time to minimize the deleterious effects of CPB on recovery. A goal of 45 minutes of cross-clamp time and 75 minutes on CPB was targeted. In addition, the temperature was allowed to drift to 32°C routinely; active cooling to a lower temperature was reserved for complex reconstructions.

Intraoperatively, triiodothyronine was administered, and postoperatively, dexamethasone, thyroxine, and early extubation techniques were used, as previously described [4, 6]. The goals during the first 24 hours postoperatively were to achieve early extubation and a negative fluid balance through active diuresis and to ensure absence of postoperative bleeding. When the intraaortic balloon pump was used, every effort was made to wean the patient from it and remove it within 12 to 24 hours postoperatively. Patients were similarly weaned from all intravenous drips without delay. In the absence of bleeding and after a successful early extubation and removal of the intraaortic balloon pump, patients were transferred to a monitored floor.

On the second postoperative day, chest drains were discontinued, and subsequently, aggressive ambulation therapy was instituted. In addition, diuretics were discontinued, and oral rehydration was permitted. When necessary, a mild cathartic (milk of magnesia) was administered on the second postoperative day.

In the morning of the third postoperative day, a shower was allowed. If at 72 hours postoperatively, the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge was planned. Central to the 3-day discharge is a supportive family that is educated in advance and reassured with a visiting home nurse as well as 24-hour access to a physician by telephone. All patients were discharged home, and follow-up with the surgeon was arranged to be within 72 hours of discharge.

A database and risk-assessment profile were completed retrospectively for each patient. Results are expressed as the mean ± the standard deviation. Comparison of continuous variables was accomplished using the t test, and categoric variables were compared with the ² test.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The 30-day operative mortality for the entire series of 104 patients undergoing isolated CABG using CPB was 1.9% (2 patients). Of the 102 survivors, 30 patients (29%) were discharged home within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Table 1 shows a comparison of the preoperative comorbidity for groups 1 and 2. There were three significant preoperative variables that distinguished the two groups: age, diabetes, and the Parsonnet risk-assessment score [13]. Patients in group 1 were younger (61.8 years versus 66.4 years; p < 0.05), fewer had diabetes (7% versus 28%; p < 0.05), and they had a lower Parsonnet score (6.9 versus 11.1; p < 0.05). In addition compared with group 2, patients in group 1 showed a trend toward a smaller proportion with congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of intraaortic balloon pump preoperatively (13% versus 35%).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

Of 102 survivors of isolated CABG with CPB, 30 (29%) were discharged home within 3 days after operation. Although discharge on the third postoperative day is ambitious, this study demonstrates that it can be accomplished safely in a substantial number of patients and with a low readmission rate (3.3%). The group of patients discharged within 3 days postoperatively was younger and had fewer comorbid conditions. The comorbid conditions found to be lower in this group included diabetes, congestive heart failure, symptomatic vascular disease, chronic obstructive pulmonary disease, ambulatory difficulties, and the requirement of an intraaortic balloon pump preoperatively.

Our criteria for a 3-day discharge include ambulation without assistance, return of normal bowel function, and absence of atrial fibrillation or any other postoperative complications. Although some postoperative complications, such as wound infections and new-onset atrial fibrillation [16], may present more than 72 hours postoperatively, there was no evidence on the basis of signs at follow-up that patients who were discharged within 3 days postoperatively had more frequent development of such late complications while at home. In fact, patients who fulfilled the criteria for 3-day discharge had a lower readmission rate, which is most likely a reflection of the lower associated preoperative comorbidity.

Coronary artery bypass grafting "off pump" has gained renewed interest because of its application to minimally invasive techniques and the associated decrease in postoperative hospital LOS. The average postoperative hospital LOS obtained by others for "off-pump" CABG when using a median sternotomy is approximately 5 days [7–10]. This result is comparable to our "on-pump" average LOS of 4.8 ± 2.4 days for the entire series. This is to be distinguished from the average LOS when using minimally invasive CABG, which is typically less than 2 days [11]; however, these patients represent a select group with single- or double-vessel disease and do not offer an ideal comparison to the "on-pump" patients requiring complete revascularization.

Although it is clear that CPB represents a finite risk with respect to a generalized inflammatory response and postoperative bleeding as well as with respect to renal, pulmonary, and neurologic dysfunction [14, 15], eliminating CPB may not be as important as simply reducing exposure. This report demonstrates that with a rapid-recovery protocol that emphasizes reduced CPB time, a substantial number of patients (29%) can be discharged within 3 days after operation and have complete surgical revascularization (3.6 ± 1.0 grafts per patient). We conclude that a 3-day discharge program is attainable and safe for low-risk patients undergoing CABG "on pump."

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Pamela Dumas for her assistance.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Ott, Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Bldg 53, Rt 81, 101 The City Dr, Orange, CA 92668.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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2. Krohn BG, Kay JH, Mendez MA, et al . Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg 1990;1001:194–7.
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard A. Ott Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ott, R. A. Articles by Tanner, T. M. Search for Related Content PubMed PubMed Citation Articles by Ott, R. A. Articles by Tanner, T. M. Related Collections Related Article