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Ann Thorac Surg 2000;69:865-871
© 2000 The Society of Thoracic Surgeons

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Original Articles

Ultra fast track in elective congenital cardiac surgery

^a Division of Cardiothoracic Surgery, Department of Surgery, Division of Cardiothoracic Surgery, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, California, USA
^b Department of Anesthesia, Division of Cardiothoracic Surgery, Loma Linda University Medical Center and Children’s Hospital, Loma Linda, California, USA

Address reprint requests to Dr Bailey, Division of Cardiothoracic Surgery, Loma Linda University Medical Center, 11175 Campus St, Suite 21120, Loma Linda, CA 92354

	Abstract

Top Abstract Introduction Case presentation Material and methods Results Comment References

 
Background. Changes in healthcare delivery have affected the practice of congenital cardiac surgery. We recently developed a strategy of limited sternotomy, early extubation, and very early discharge, and reviewed the perioperative course of 198 pediatric patients undergoing elective cardiovascular surgical procedures, to assess the efficacy and safety of this approach.

Methods. One hundred ninety-eight patients aged 0 to 18 years (median 3.2 years) underwent 201 elective cardiovascular surgical procedures over a 1-year period. All patients were admitted on the day of surgery. Patients were divided into six diagnostic groups: group 1, complex left-to-right shunts (n = 14, 7.0%); group 2, simple left-to-right shunts (n = 83, 41.3%); group 3, right-to-left shunts with pulmonary obstruction (n = 33, 16.4%); group 4, isolated, nonvalvular obstructive lesions (n = 30, 14.9%); group 5, isolated valvular anomalies (n = 20, 10.0%); and group 6, miscellaneous (n = 21, 10.4%).

Results. After 201 procedures, 175 patients (87.1%) were extubated in the operating room and 188 (93.6%) within 4 hours from operation. Four patients (2.0%) were extubated more than 24 hours from completion of the procedure, and 2 (1.0%) died while on respiratory support (never weaned). Five patients (2.6%) failed early extubation (<4 hours). Early discharge was achieved for the vast majority of patients. Overall median length of stay (LOS, including day of surgery as day 1) was 2.0 days, with a median LOS of 3.0 days for those patients requiring circulatory arrest duration exceeding 20 minutes. Of 195 patients, 43 (24.6%), 121 (74.0%), and 159 (81.5%) were discharged, respectively, at < 24, < 48, < 72 hours from admission. Longest and shortest mean postoperative LOS were in group 6 (9.9 ± 14.5 days) and group 2 (1.6 = 0.7 days), respectively. Six patients (2.9%) died, and 11 (5.5%) suffered in-hospital complications. Thirty patients (15.4%) were either treated as outpatients (n = 11, 5.7%) or readmitted (n = 19, 9.7%) within 30 days from the time of surgery. Only 8 of 195 patients (4.1%) were readmitted with true surgical complications requiring invasive therapeutic procedures.

Conclusions. Selected patients with a broad spectrum of congenital heart disease may enjoy same-day admission, limited sternotomy, immediate extubation, and very early discharge with excellent outcomes and acceptable morbidity.

	Introduction

Top Abstract Introduction Case presentation Material and methods Results Comment References

 
Changes in healthcare delivery have influenced all aspects of medical practice, including the field of congenital cardiac surgery. Cost containment, limitation of laboratory evaluation and monitoring, and early discharge have all been emphasized. We have recently developed a strategy of same-day admission, limited sternotomy, immediate extubation, and very early discharge for infants and children undergoing elective correction of palliation of cardiovascular anomalies. We reviewed a series of 198 patients managed by means of this strategy, in order to assess efficacy and safety of this approach.

	Case presentation

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A 6-month-old female (weight 4.8 kg) is admitted on the day of surgery for repair of a perimembranous ventricular septal defect (VSD), secundum type atrial septal defect (ASD), and patent ductus arteriosus (PDA). All preoperative workup and blood crossmatching are done on the day before admission. The patient undergoes repair of all defects through a limited sternotomy with cardiopulmonary bypass (CPB) and cross-clamp (CCT) times of 66 and 27 minutes, respectively. The lowest core temperature is 18°C. She is extubated in the operating room after chest roentgenogram (CXR) and transferred to the intensive care unit, where a complete blood count and basic electrolytes are obtained. The indwelling urinary catheter and radial arterial monitoring line are removed at 4 hours, and the infant is fed at 5 hours postoperatively (older children are ambulated with assistance at this time). The following morning, only a CXR is obtained after removal of the mediastinal drain. The central venous catheter is removed and the patient is discharged home at 18 hours from completion of the surgical procedure.

	Material and methods

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Three hundred thirty-six patients (0 to 18 years of age) underwent cardiothoracic surgical procedures at Loma Linda University Medical Center and Children’s Hospital between July 1, 1995 and June 30, 1996. For the purpose of this study, the following groups of patients were excluded: cardiac transplants (n = 23), premature newborns undergoing patent ductus arteriosus ligation (n = 27), general thoracic procedures (n = 26), and inpatients (n = 59).

After exclusion of these patients, the hospital course of 198 infants and children undergoing 201 elective cardiovascular surgical procedures was reviewed. Complete data were available for all patients who met the study criteria. The 96 females (48.5%) and 102 males (51.5%) were all admitted on the day of surgery. They were divided into six diagnostic groups, according to their anatomical and physiological characteristics (Table 1).

Univariate outcome logistic regression analysis was performed for several pre- and intraoperative variables, with statistical significance accepted at the 95% confidence level (p < 0.05). Results are expressed as median unless otherwise specified. For continuous data, variability was reflected by ± standard deviation. Statistical analysis was obtained by standard, commercially available software (SPSS Inc, Chicago, IL).

	Results

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All patients were admitted on the day of surgery. Main preoperative characteristics of the different diagnostic groups are summarized in Table 2. Median age and weight of the 198 patients were 3.2 years and 13.0 kg. Preoperative pulmonary hypertension (n = 3, 21.4%) and congestive heart failure (n = 10, 71.4%) were higher in patients in group 1, who were also the smallest cohort with regards to age and weight. Patients in group 6 underwent the larger number of reoperative (n = 17, 80.9%) as well as palliative (n = 9, 42.9%) procedures. Infants and children requiring different stages of Fontan palliation were included in this group.

Early extubation was achieved for the vast majority of the 201 patients (Fig 1). Immediate extubation (at completion of the procedure, in the operating room) was accomplished in 175 patients (87.1%). One hundred eighty-eight patients (93.6%) were extubated within 4 hours. Four patients (2.0%) were extubated at more than 24 hours from operation, while 2 patients (1.0%) died while intubated, having never been weaned from mechanical respiratory support. Fifteen of the 22 patients (68.2%) in the group with HCA duration exceeding 20 minutes were extubated in the operating room, with 19 of these (86.4%) extubated within 4 hours. On univariate regression analysis, requirements of HCA in excess of 20 minutes was a negative predictor of extubation in the operating room (p = 0.011), but not for extubation within 4 hours. No statistically significant differences were noted between CPB and non-CPB cases with regards to immediate extubation or extubation within 4 hours. Delayed extubation (> 24 hours) was caused by seizure (n = 1), reperfusion pulmonary injury requiring extracorporeal membrane oxygenation (n = 1), and hemodynamic instability (n = 2). Only 5 of 188 patients (2.7%) failed early (< 4 hours) extubation and required reintubation.

View larger version (20K): [in this window] [in a new window]   Fig 1. Early extubation. (OR = extubated in the operating room; DOMV = died on mechanical ventilation.)

View larger version (24K): [in this window] [in a new window]   Fig 2. LOS/time of discharge for 195 patients. (LOS = length of stay; D/C’d = discharged; In-Pts = inpatients.)

The postdischarge course of the 195 patients discharged is outlined in Figure 3. Thirty patients (15.4%) made unscheduled visits to the ED, cardiothoracic surgery clinic, or pediatric clinic within 30 days from operation with minor or major complaints. Nineteen patients (9.7%) were readmitted and 11 (5.7%) were treated as outpatients. Among those readmitted, 8 underwent either reoperation (n = 2, 1.0%), or invasive drainage procedures without sequelae (n = 6, 3.1%). Eleven of 195 patients discharged (5.7%) had complaints unrelated to surgery, while 19 (9.7%) were of surgical concern. Of the latter group, postpericardiotomy syndrome (PPS, n = 8) and pleural effusions (n = 6) accounted for the vast majority (14/19, 73.7%) of surgical problems. Specifically, 1 of 7 patients with PPS required pericardiocentesis as an inpatient, while 5 of 6 patients with pleural effusion required readmission and drainage. Five of the six pleural effusions occurred in patients in group 6. Patients with PPS/pleural effusion first presented at a median of 13 days from the procedure (range 4 to 30 days). Two patients (1.0%) required reoperation for a retained cannula fragment and for persistent aortic insufficiency after initial repair. There was no postdischarge 30-day mortality.

View larger version (17K): [in this window] [in a new window]   Fig 3. Postdischarge course of 195 patients discharged. (AI = aortic insufficiency; D/C = discharged; ER = emergency room; OR = operating room.)

	Comment

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The field of cardiac surgery particularly lends itself to the use of this approach [1–3]. Children with congenital heart disease undergoing elective correction or palliation are an excellent substrate for fast-track methodology. They usually reach the time of operation in stable condition with nothing more than medically managed congestive heart failure, cyanosis, or failure to thrive. As compared with adults undergoing cardiac surgical procedures [4], the incidence of preoperative comorbidities is relatively minimal. Turley and coworkers first reported the use of the radical outcome method (ROM) and the critical pathway method (CPM) in the management of patients with congenital heart disease (with 14 days of follow-up), attempting to minimize variation in the clinical process [5, 6].

Despite the relatively "healthy" preoperative status of most elective surgical patients, considerable debate surrounds the issue of same-day admission for cardiac surgical patients [7]. Patients with congenital heart disease who do not require inpatient status on the basis of preoperative decompensation likely do not benefit from preadmission. They are among the most stable of patients. Clinical outcomes of preoperatively hospitalized infants with congenital heart disease have been previously investigated [8, 9]. We have specifically chosen, as subject of this report, those pediatric patients who were admitted on the day of surgery, and who presented with a broad variety of congenital cardiac anomalies. These patients, who require elective cardiovascular procedures, stand to benefit most from an accelerated pathway of management and early discharge. Some of the principles of ultra fast track (reduced invasive monitoring, early extubation, and fewer laboratory tests) are applicable, in our opinion, to nonelective congenital heart surgery as well. However, application of such principles to the inpatient population is unlikely to reduce LOS to the extent demonstrated in this study, owning to the substantial preoperative morbidity.

Some authors have suggested that in comparison with adults, pediatric myocardium (especially in infants within the first year of life) might be more vulnerable to ischemia and reperfusion injury after procedures using CPB [10], thereby justifying a "go slow" approach to extubation and discharge in the pediatric patient. By contrast, in the elective pediatric setting, we have seldom observed myocardial failure and significant hemodynamic impairment. We have used, and continued to use in the study, an intraoperative strategy based on straight hemodilution, ultrafiltration during bypass, and liberal use of hypothermic low-flow perfusion coupled, as necessary, with intermittent periods of HCA. Perioperative inotropic support and blood transfusions have been minimized.

Patient selection is also based on family environment, reliability, and access to postdischarge follow-up. Preoperative family education is crucial and is commenced during the days and weeks immediately preceding the day of surgery. The child’s parents are educated with audiovisual material and on-site visits about the anticipated hospital course and possible deviations from the expected recovery pathway. Teaching of basic resuscitative techniques as well as monitoring for signs and symptoms of potential postoperative complications is performed again before patient discharge. The patient has immediate access to the cardiac surgical team through a dedicated fast-track nurse coordinator. As a result, perioperative (first 30 postoperative days) triage is usually successful in bypassing the ED or the pediatrician’s office. The patients and their families are invariably evaluated in the surgeon’s outpatient office within the first postdischarge week. Families are also contacted by telephone on a regular basis for the first 4 postoperative weeks, to confirm a stable and uneventful postdischarge recovery.

Immediate extubation after complex congenital cardiac surgery (in particular after procedures requiring HCA) is a novel concept that has scarcely been reported in the literature [11, 12]. Though not rigidly standardized, most of the children in this series received similar anesthetic management. Premedication was given to most patients over 6 months of age utilizing midazolam (0.5 mg/kg), while others received intramuscular morphine or scopolamine. Either halotane inhalation or intramuscular ketamine (for patients with depressed ventricular function) were used for induction in patients without intravenous (IV) access. For those with IV access, sodium thiopental or IV ketamine were utilized, depending on the patient’s condition. Narcotics consisted of fentanyl (10 to 12 µg/kg total) for the entire case, titrated on induction, skin incision, CPB, and as indicated by vital sign variations. Maintenance anesthesia consisted of isoflorane titrated to the patient’s response. Pancuronium was the primary muscle relaxant, with shorter acting agents (rocuronium) titrated after CPB. Neostigmine and atropine were administered during skin closure. Standard pediatric extubation criteria, as well as portable CXR, were used to determine suitability for immediate extubation. Use of inotropic support was not considered among extubation criteria if patient hemodynamics were stable. Immediate (within 15 minutes from skin closure) or early (within 4 hours) extubation was accomplished for the vast majority of patients in this series (Fig 1).

Five patients (2.6%) failed early (4 hours) extubation. These children were all extubated in the operating room. Four required HCA, the duration of which ranged between 8 and 49 minutes. Causes for reintubation (1 patient each) were seizures (48 hours), decompensation caused by residual VSDs (2 hours), onset of postoperative hemorrhage with lung collapse (4 hours), excessive sedation with CO₂ retention (immediate), and hemodynamic instability (9 hours). Three of these children nevertheless achieved satisfactory recovery and were discharged at 18 hours, 4 and 5 days postoperatively. Of the 5 patients, only 1 (0.5% of all < 4 hours extubation) failed because of respiratory failure with CO₂ retention. Brief reintubation did not interfere with his discharge on the first postoperative day. Early extubation was also achieved successfully in the majority of children undergoing repair and palliation requiring significant increments of HCA. Of the patients requiring duration of HCA above 20 minutes, 68.2% and 86.4% were successfully extubated in the operating room or within 4 hours from completion of the procedure, respectively. It is hard to predict whether early extubation per se was a causative factor in delayed mortality of 2 patients initially extubated in the operating room. Death occurred at 34 days after decompensation and reoperation for residual ventricular shunting in a patient with "Swiss cheese" ventricular septum. The other infant was reintubated for management of progressive heart failure 9 hours after operation, and expired on postoperative day 43 from multisystem organ failure.

As might be intuitively predicted, median LOS was slightly higher in groups 1 and 6 (Table 4). For patients in group 6, longer LOS occurred largely on the basis of prolonged chest tube drainage. Use of soft, silastic quadri-lumen bulb suction drains containing Heimlich valves (Blake drain; Johnson & Johnson Co, Cincinnati, OH) has recently permitted earlier patient discharge. Drains are then removed in the outpatient office. One patient in group 6 had a LOS of 66 days. This infant suffered an intracranial hemorrhage into a previously undiagnosed cerebral arteriovenous malformation. His hospital course was complicated by meningitis, sepsis, and renal failure requiring peritoneal dialysis. A subsequent intracranial bleed caused his demise, 6 months after his cardiac surgical procedure.

Univariate logistic regression analysis for both categorical and continuous variables was carried out to assess which of the pre- and intraoperative data reviewed were associated with statistical significance to in-hospital morbidity, LOS longer than 48 hours, postdischarge surgical morbidity, and mortality (Table 5). Diagnostic group (1 and 6) and extubation somewhere other than the operating room reached statistical significance as predictors of all four outcome variables. Use and duration of HCA in excess of 20 minutes was associated with both increased in-hospital morbidity and LOS more than 48 hours, but not with higher mortality and postdischarge morbidity. Preoperative congestive heart failure was associated with increased mortality. Reoperative procedure was a strong predictor of extended LOS.

After discharge, a substantial proportion of unscheduled return visits was caused by nonspecific symptoms (n = 11, 5.7% of 195 discharges). Pleural and pericardial effusions represented the majority (73.6%) of complications clearly related to surgery. These effusions became symptomatic at a median of 13 days from the operative procedure, making prolonged hospitalization unlikely to benefit the course of these patients. After this experience, we have instituted a phone triage system and moved towards outpatient drainage of pericardial or pleural effusions, limiting readmission to those patients who truly require monitored care.

Conclusions
Patients with a broad spectrum of congenital cardiac pathology undergoing elective repair may be managed with an "ultra fast-track" strategy, without increased morbidity and mortality. Limited sternotomy, immediate extubation, and very early discharge may be safely accomplished among the vast majority of patients, including those requiring complex repair or duration of hypothermic circulatory arrest in excess of 20 minutes. Prolonged unnecessary hospitalization contributes little, if any, to a more favorable therapeutic outcome. Family reliability and ready access to the cardiac surgical team will result in satisfactory outpatient resolution of most late-onset complications.

	References

Top Abstract Introduction Case presentation Material and methods Results Comment References

 

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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): Luca A. Vricella Joseph A. Dearani Steven R. Gundry Anees J. Razzouk Leonard L. Bailey Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vricella, L. A. Articles by Bailey, L. L. Search for Related Content PubMed PubMed Citation Articles by Vricella, L. A. Articles by Bailey, L. L. Related Collections Related Article