HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) 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): Jai H. Lee Helen K. Murrell Alexander S. Geha Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, J. H. Articles by Geha, A. S. Search for Related Content PubMed PubMed Citation Articles by Lee, J. H. Articles by Geha, A. S.

Ann Thorac Surg 1999;68:437-441
© 1999 The Society of Thoracic Surgeons

---

Original Articles

Fast track recovery of elderly coronary bypass surgery patients

^a Division of Cardiothoracic Surgery, University Hospitals of Cleveland, Cleveland, Ohio, USA

Address reprint requests to Dr Lee, Division of Cardiothoracic Surgery, University Hospitals of Cleveland, Cleveland, OH 44106

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon.

Methods. Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years).

Results. The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14% ± 9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13% ± 7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6 ± 2.8 days versus 7.2 ± 3.7 days; 95% CI, 1.6 ± 0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients.

Conclusions. Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The interest in early extubation and fast-track treatment of cardiac surgical patients is driven largely by economic considerations. Outcome studies have focused on the applicability of fast-track recovery to younger, low-risk patients [1, 2]. We and others have documented the enormous potential for cost containment with this approach [3, 4]. The appeal of fast-track protocols is that the cost savings were not associated with increased morbidity or mortality rates [1–3]. In fact, there is evidence that fast-track protocols could enhance patient outcome [5].

Early reports excluded elderly patients from such protocols [6]. A recent report by Ott and associates [7] on fast-track recovery in an elderly population stimulated us to determine whether major modifications in the critical pathway were necessary to achieve comparable outcomes in an elderly population undergoing isolated coronary bypass operations.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
All patients who had isolated coronary bypass operations between January 1995 and June 1997 were included, constituting the experience of a single surgeon (J.H.L.) at the University Hospitals of Cleveland. This analysis includes all urgent, emergent, and catherization salvage cases, as well as reoperations. The study included 176 patients age 70 years or older who were compared with 311 patients less than 70 years old. This analysis excludes patients who had minimally invasive coronary bypass surgery without cardiopulmonary bypass.

There were four hospital deaths (0.8%), and 10 patients (2.0%) had complicated postoperative courses with prolonged hospitalizations (> 21 days). All these patients were included in the length of stay analysis. Data for each patient were collected by a cardiovascular care manager during hospitalization and after discharge in order to identify complications and readmissions.

Definitions
For the purpose of this study, early extubation is defined as removal of the endotracheal tube from the patients within 8 hours of arrival to the surgical intensive care unit. This definition has been used in previous reports [8]. Operative death was defined as death occurring within 30 days of operation or during the same hospital stay. Renal failure or insufficiency was considered to be present in patients with a preoperative serum creatinine level greater than 2.0 mg/dL and who were receiving hemodialysis or peritoneal dialysis preoperatively. Perioperative myocardial infarction was defined as new Q waves in two or more contiguous leads on a 12-lead electrocardiogram. Postoperative stroke was diagnosed if a persistent neurologic deficit was present at discharge. Mediastinitis was defined as a sternal wound infection requiring a second surgical procedure for closure.

Surgical and anesthetic technique
All procedures were done using cardiopulmonary bypass with moderate hemodilution (hematocrit value of 21% to 27%). Cardiopulmonary bypass was instituted by using an ascending aortic cannula and two-stage venous cannula. The perfusion temperature was allowed to decrease to 32°C. Cooling to lower temperatures was not done. Cardioplegia was delivered by an aortic cardioplegia venting cannula initially, followed by retrograde administration after construction of each distal anastomosis. A modification for patients with ongoing ischemia consisted of using warm cardioplegia for induction of cardiac asystole. All distal and proximal anastomoses were constructed during a single cross-clamp period. The proximal anastomoses were constructed as warming was initiated so that, when the terminal substrate-enriched dose of warm cardioplegia was administered before removal of the cross-clamp, a perfusion temperature of 37°C was reached.

The anesthetic protocol included the increased use of inhalational agents and propofol, and the use of lower dosages of narcotics. Patients underwent induction of anesthesia with either etomidate or thiopenthal sodium, supplemented with midazolam and fentanyl or sufentanil. Total fentanyl and sufentanil doses were 10 to 25 µg/kg and 2 to 3 µg/kg, respectively. Total midazolam doses were less than 0.1 mg/kg. Anesthesia was maintained with either isoflurane and/or propofol at the discretion of the attending anesthesiologist. Intraoperative monitoring included radial artery pressure, electrocardiography, pulmonary artery catheters, esophageal temperature, end-tidal capnography, and pulse oximetry, all of which were continued into the postoperative period. Intravenous administration of nitroglycerin and diltiazem was started after the patient was brought to the operating room and was continued for 24 hours postoperatively.

Postoperative pain was managed with morphine and ketorolac. Approximately 80% to 90% of patients were sedated short term with low-dose propofol infusions. Propofol was administered in a range of 0 to 20 mL/h, titrated at the discretion of the patient’s nurse to achieve a score of 3 on the Ramsey scale. Ventilatory weaning was facilitated by a nurse and respiratory therapist who ran weaning protocol. Patients were extubated when they met standard extubation criteria.

In contrast to previously reported protocols [7], corticosteroids and triiodothyroxine were not administered during the perioperative period. Patients with serum creatinine level higher than 1.6 mg/dL received renal-dose dopamine, which was continued for 24 to 36 hours postoperatively. During the second and third postoperative days, ambulation was encouraged. If the patient was able to ambulate without assistance, had resumed normal bowel function, and was without evidence of atrial fibrillation, discharge was planned.

Statistical analysis
All data were collected prospectively on standardized forms and entered into a computerized database (Summit Medical Inc, Minneapolis, MN). All data are expressed as mean ± standard deviation or as percentages, where appropriate. Clinical and operative differences between the two groups were tested for statistical significance by using t tests and confidence intervals for the difference of the two means. Differences in percentages were tested using the ² test or Fisher’s exact test for small expected frequencies, as appropriate. Stepwise multiple logistic regression analysis was used to assess the independent contributions of multiple variables to the development of atrial fibrillation and to prolonged length of stay.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Clinical profile
The distribution of important demographic, clinical, and catheterization findings for the study group are depicted in Table 1. Patients’ ages ranged from 33 to 87 years with a mean of 65 years. The proportion of patients older than 70 years who were women was higher than the proportion of women in the younger group. The older population was significantly sicker in terms of comorbidities, particularly congestive heart failure (p < 0.001), peripheral vascular disease (p < 0.001), and renal failure (p < 0.001). The older patients also were more likely to have had a history of a stroke (p < 0.02) and had a higher incidence of cerebrovascular and carotid disease at time of operation (p < 0.001). Although mean left ventricular ejection fraction was similar, a greater proportion of elderly patients had impaired left ventricular ejection fraction defined to be less than 40% at time of surgery (40.5% versus 31.0%; p = 0.03). The mean body weight of the elderly was 10 kg less than that of the younger patients.

The impact of age in 321 of 487 patients who were extubated in less than 8 hours is depicted in Figure 1. Early extubation declined with increasing age. Nonetheless, greater than half of the septuagenarians and octogenarians were extubated early. Seventy-one percent of the younger cohort of patients were extubated early versus 57% of the older cohort of patients (p < 0.002). Reintubation rates were negligible in both groups of patients.

View larger version (21K): [in this window] [in a new window]   Fig 1. Early extubation rates by age group.

Among preoperative variables, age higher than 70 years, congestive heart failure, preoperative intraaortic balloon counterpulsation, cerebrovascular disease, left ventricular ejection fraction less than 40, and history of renal failure were the strongest predictors of increased length of stay (p < 0.001) by univariate analysis. By multivariate analysis, advanced age (odds ratio 3.3; 95% CI, 2.2, 5.1) and congestive heart failure (odds ratio 2.9; 95% CI, 0.8, 10.7) remained independent predictors of increased length of stay.

Readmission to our hospital as well as to other hospitals was similar for both cohorts of patients (Table 4). If one examines readmission rates to the hospital performing the coronary bypass operation, they understate the magnitude of this problem. Thus, all patients were contacted at 30 days postoperatively, and all readmissions to other institutions were included in our database. Approximately half of the readmissions were for treatment of atrial fibrillation and recurrent heart failure or fluid overload, whereas the remainder were due to a variety of miscellaneous reasons, including pleural effusions and wound infections. Early discharge from the hospital was not a factor in readmission rates. Patients discharged before the fifth postoperative day had lower rates of readmission versus patients discharged later (37% versus 63%; p < 0.05).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Because the elderly represent the fastest growing segment of the United States population, an increasing number of elderly patients are being referred for myocardial revascularization. However, previous studies found increased risk for elderly patients undergoing coronary bypass surgery [9, 10]. Thus, most reports have excluded elderly patients from early extubation protocols, because careful patient selection is important in assuring a successful outcome. The reluctance to apply early extubation protocols to elderly cardiac surgical patients derives from previous analyses of determinants of prolonged mechanical ventilation. Two recent reports found that advanced age is an independent predictor of delayed extubation after coronary bypass operation [11, 12]. In addition, changes in the respiratory system of elderly patients make them more prone to postoperative hypoxemia and hypercarbia.

However, there is convincing data that early extubation not only is feasible, but preferable in most patients who have cardiac operations [3, 5, 8]. The potential benefits of early extubation include improved ciliary function and earlier ability to cough. Cheng and associates [5] demonstrated in a prospective randomized study that intrapulmonary shunt fraction improved significantly among patients extubated early. Mechanical ventilation itself can impair venous return and decrease cardiac output [13]. Thus, it might not be appropriate to exclude the elderly from the benefits of early extubation.

We did not to use preoperative comorbidities as exclusionary criteria for early extubation. Instead, all patients regardless of age were set up for early extubation, and their postoperative status determined the actual time of extubation. Patients were extubated when they met standard criteria, including being awake, warm, not bleeding, hemodynamically stable, with adequate oxygenation and ventilatory effort.

Knowledge of pharmacologic and pharmacokinetic changes in the elderly helps to facilitate early extubation. Because of changes in the central nervous system and changes in the metabolism of drugs, careful titration of drugs is important. The elderly are generally more sensitive to drugs that depress the central nervous system, and they should be administered in reduced dosages. Since the elimination half-lives of fentanyl and midazolam are prolonged 3 to 4 times in the elderly, the doses are reduced by about 50%. Early extubation continues to be a dynamic process, and although more than half the elderly patients in this study were extubated early, we anticipate that with further refinements of dosages among elderly patients, a higher percentage can be extubated early. The data reported herein confirm the safety of early extubation of elderly patients.

The use of corticosteroids to blunt the inflammatory process after coronary bypass operations has been advocated as a crucial element in the fast-track protocol [1]. This technique has been extended to the elderly population by Ott and colleagues [7]. Our experience suggests that perioperative corticosteroids might not be necessary to achieve rapid recovery. The administration of intravenous triiodothyronine at the initiation of cardiopulmonary bypass followed by intravenous thyroid hormone administration for the first 48 hours postoperatively could expedite early recovery [7]. However, two recent clinical studies found that intravenous triiodothyronine produced only modest hemodynamic changes and therefore did not alter the need for postoperative inotropic therapy and, more importantly, did not change outcome [14, 15]. Based on the available data, intravenous triiodothyronine should not be used routinely among patients who have coronary bypass operations, although it might have some benefit in decreasing the incidence of postoperative atrial fibrillation.

Preoperative intra-aortic balloon counterpulsation was used in less than 5% of our elderly patients. This percentage is comparable to other recent reports [1, 2] but distinctly different from others [7] in which intra-aortic balloon counterpulsation was used in 50% of the patients and enhanced rapid recovery of elderly patients. Our data suggest that overuse of intra-aortic balloon counterpulsation is not crucial to expedite rapid recovery among the elderly, although some patients might have benefitted from preoperative intra-aortic balloon counterpulsation.

As in previous studies, age remains a significant risk factor for postoperative atrial fibrillation [16]. In the present study, advanced age remained a significant predictor of atrial fibrillation after adjusting for the covariates listed in Table 1. The incidence of atrial fibrillation was 26% among elderly versus 14% among young patients (p = 0.003). Although prophylaxis is important, there remain an irreducible minimal number of patients who develop postoperative atrial fibrillation. Strategies advocated to minimize length of stay include discharge from hospital after anticoagulation regardless of the atrial sinus rhythm [17]. Our discharge criteria mandate maintenance of normal sinus rhythm for at least 24 hours before discharge if the patient had normal sinus rhythm preoperatively. Thus, efforts are directed at prompt recognition and treatment of atrial fibrillation. Our protocol implements intravenous diltiazem for rate control and procainamide for either recurrent atrial fibrillation or atrial fibrillation that persists longer than 4 hours. We believe that such protocols eliminate the haphazard and inconsistent treatment of postoperative atrial fibrillation and reduce length of stay for this complication [18].

Although the findings of this study are consistent with results from other series, the data are nevertheless limited by the retrospective nature of analysis, the relatively small number of patients, and the fact that all patients were operated on by a single surgeon. The latter consideration limits extrapolation.

In conclusion, fast-track treatment produced favorable in-hospital and interim clinical outcomes in the elderly compared with younger patients. Age should not be a determinant for the appropriateness of early extubation and subsequent fast-track recovery. Current clinical pathways without major modifications achieve outcomes in patients who are 70 years of age or older comparable to those of younger patients.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Engleman R.M., Rousou J.A., Flack J.E., et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994;58:1742-1746.[Abstract]
2. 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.[Abstract/Free Full Text]
3. Lee J.H., Kim K.H., vanHeeckeren D.W., et al. Cost analysis of early extubation after coronary bypass surgery. Surgery 1996;120:611-619.[Medline]
4. Cheng D.C. Pro. J Cardiothorac Vasc Anesth 1995;9:460-464.[Medline]
5. Cheng D.C., Karski J., Peniston C., et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;112:755-764.[Abstract/Free Full Text]
6. Higgins T.L. Safety issues regarding early extubation after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1995;9:24-29.[Medline]
7. Ott R.A., Gutfinger D.E., Miller M.D., Alimadadian H., Tanner T. Rapid recovery after coronary artery bypass grafting. Ann Thorac Surg 1997;63:634-639.[Abstract/Free Full Text]
8. Higgins T.L. Pro. J Cardiothorac Anesth 1992;6:488-493.
9. Weintraub WS, Craver JM, Cohen CL, Jones EL, Guyton RA. Influence of age on results of coronary artery surgery. Circulation 1991;84(Suppl 5):III226–35.
10. Hannan E.L., Burke J. Effect of age on mortality in coronary artery bypass surgery in New York, 1991–1992. Am Heart J 1994;128(Pt 1):1184-1191.[Medline]
11. Habib R.H., Zacharias A., Engoren M. Determinants of prolonged mechanical ventilation after coronary artery bypass grafting. Ann Thorac Surg 1996;62:1164-1171.[Abstract/Free Full Text]
12. Bando K., Sun K., Binford R.S., Sharp T.G. Determinants of longer duration of endotracheal intubation after adult cardiac operations. Ann Thorac Surg 1997;63:1026-1033.[Abstract/Free Full Text]
13. Gall S.A., Olsen C.O., Reves J.G., et al. Beneficial effects of endotracheal extubation on ventricular performance. J Thorac Cardiovasc Surg 1988;95:819-827.[Abstract]
14. Klemperer J.D., Klein I., Gomez M., et al. Thyroid hormone treatment after coronary artery bypass surgery. N Engl J Med 1995;333:1522-1527.[Abstract/Free Full Text]
15. Bennett-Guerrero E., Jimenez J.L., White W.D., et al. Cardiovascular effects of intravenous triiodothyronine in patients undergoing coronary artery bypass graft surgery. JAMA 1996;275:687-692.[Abstract/Free Full Text]
16. Leitch J.W., Thomson D., Baird D.K., Harris P.J. The importance of age as a predictor of atrial fibrillation and flutter after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1990;100:338-342.[Abstract]
17. Solomon A.J., Kouretas P.C., Hopkins R.A., Katz N.M., Wallace R.B., Hannan R.L. Early discharge of patients with new-onset atrial fibrillation after cardiovascular surgery. Am Heart J 1998;135:557-563.[Medline]
18. Lee J.H., Challapalli S., Effron B., et al. Impact of an arrhythmia protocol on reducing length of stay for postoperative atrial fibrillation. Chest 1996;110(Suppl):23S.[Free Full Text]

This article has been cited by other articles:

				N. Charokopos, P. Antonitsis, M. Toumbouras, J. Konstantinopoulos, and E. Rouska Influence of Fast-Track Recovery after Coronary Artery Bypass in the Elderly Asian Cardiovasc Thorac Ann, April 1, 2007; 15(2): 144 - 148. [Abstract] [Full Text] [PDF]

				P. A. Cowper, E. R. DeLong, E. L. Hannan, L. H. Muhlbaier, B. L. Lytle, R. H. Jones, W. L. Holman, J. J. Pokorny, J. A. Stafford, D. B. Mark, et al. Is Early Too Early? Effect of Shorter Stays After Bypass Surgery Ann. Thorac. Surg., January 1, 2007; 83(1): 100 - 107. [Abstract] [Full Text] [PDF]

				T. Athanasiou, S. Al-Ruzzeh, P. Kumar, M.-C. Crossman, M. Amrani, J. R. Pepper, R. Del Stanbridge, R. Casula, and B. Glenville Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients Ann. Thorac. Surg., February 1, 2004; 77(2): 745 - 753. [Abstract] [Full Text] [PDF]

				C. Alhan, F. Toraman, E. H. Karabulut, S. Tarcan, S. Dagdelen, N. Eren, and N. Caglar Fast track recovery of high risk coronary bypass surgery patients Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 678 - 683. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, G. Scipioni, G. Teodori, G. Di Giammarco, M. Di Mauro, C. Canosa, A. L. Iaco, and G. Vitolla Day 0 intensive care unit discharge -- risk or benefit for the patient who undergoes myocardial revascularization? Eur. J. Cardiothorac. Surg., March 1, 2002; 21(3): 377 - 384. [Abstract] [Full Text] [PDF]

				M. Capdeville and J. H. Lee Off-Pump Coronary Artery Bypass Surgery: Revival of an Old Technique Seminars in Cardiothoracic and Vascular Anesthesia, November 1, 2001; 5(4): 345 - 361. [Abstract] [PDF]

				H. L. Lazar, C. A. Fitzgerald, T. Ahmad, Y. Bao, T. Colton, O. M. Shapira, and R. J. Shemin Early discharge after coronary artery bypass graft surgery: Are patients really going home earlier? J. Thorac. Cardiovasc. Surg., May 1, 2001; 121(5): 943 - 950. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Jai H. Lee Helen K. Murrell Alexander S. Geha Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, J. H. Articles by Geha, A. S. Search for Related Content PubMed PubMed Citation Articles by Lee, J. H. Articles by Geha, A. S.