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Ann Thorac Surg 2005;79:345-346
© 2005 The Society of Thoracic Surgeons
a Carolina Heart Institute, Greenwood, South Carolina, USA
Accepted for publication August 19, 2003.
* Address reprint requests to Dr Bolton, Carolina Heart Institute, 303 W Alexander Ave, Suite E, PO Box 3284, Greenwood, SC 29648, USA
rbolton{at}carolinaheartinstitute.com
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Abstract |
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Introduction |
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A 68-year-old diabetic male presented to the emergency department with a two-day history of intermittent substernal chest pain radiating to his left arm. The remainder of his history was only significant for a 100 pack per year history of smoking. His physical examination was unremarkable. Electrocardiogram performed on presentation showed normal sinus rhythm with left axis deviation, left anterior fascicular block, significant Q waves anteriorly V1–V3 with corresponding T-wave inversions anterior laterally. Troponin I level was 4.9 and peaked at 6.1. The patient was begun on aspirin, intravenous nitroglycerin, low molecular weight heparin, and Integrilin with the anticipation of cardiac catheterization.
An echocardiogram on his first hospital day revealed anterior wall and septal hypokinesis and apical akinesis, with an estimated left ventricular ejection fraction (LVEF) of 30% to 35%. On his second hospital day he underwent cardiac catheterization, which revealed a 95% stenosis of the left anterior descending (LAD) coronary artery after the first diagonal artery as well as a 90% stenosis of the proximal circumflex artery. The remainder of his coronary anatomy was without significant disease. Based upon his coronary anatomy and presentation, cardiac surgery was consulted and the patient was taken to the operating room at 7:30 am on hospital day 6. He underwent an uncomplicated two-vessel OPCAB via sternotomy, utilizing the left internal mammary artery to the mid-LAD and saphenous vein graft from the ascending aorta to the first obtuse marginal branch of the circumflex artery.
The patient was extubated in the operating room and arrived in the cardiac intensive care unit at 9:22 am without inotropic support and with intravenous Precedex for pain relief. His family visited at 10:00 am and he had breakfast at 10:50 am. By 12:30 pm he was medicated with one Vicodin and was sitting up. Due to a decrease in blood pressure to 104/40 mm Hg, the patient received 500 mL of saline. The mediastinal tube and urinary catheter were discontinued by protocol at 2:00 pm and the patient was ambulated in the hall at 3:00 pm. He was once again medicated with Vicodin for incisional pain at 4:15 pm and was resting with room air saturations of 96% at 5:00 pm. He voided at 5:30 pm and ambulated without difficulty with saturations of 96% at 6:00 pm. By 6:20 pm the patient was in good spirits and was asking to go home. Following discussions with the patient and his family, and since the patient had accomplished all of the usual predischarge activities, he was discharged to home.
As routine, he was contacted by telephone on the day following his discharge and was having no problems and without complaint. He returned for follow-up two-weeks following his operation and was found to have well-healing wounds and doing well.
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In the evolution to outpatient CAB, there are paradigm changes which must occur within the system with the primary caveat that the welfare of the patient is the primary concern. Such a program may be evaluated by examining changes in the preoperative expectation, changes in the operating suite, and changes in postoperative care.
Probably the most important preoperative change is that of attitude. The patient and their family must expect to be discharged the day following the operation. Being fully informed of the process and stepwise progression greatly facilitates this. Old ideas of week-long hospital stays are supplanted with the confident realization that the patient will do well upon early discharge home.
Quite often, it is more difficult to affect a change in the attitude of referring physicians. These attitudes do not change overnight, but as the patients return to the care of these physicians, there is a noticeable difference.
The next change and in many ways the key to the process, is that of the operating suite. The mentality of the team is very important. The techniques of OPCAB are well described and are becoming more standardized. However, communication between anesthesiologist and surgeon is paramount for a smooth case. The anesthesiologist must plan for a different strategy of extubation in the operating room. This sets the stage for the remainder of the hospital stay. In order for this to be routinely accomplished careful thought must be given to immediate postoperative pain management. Some techniques we have found helpful include the use of Toradol, Precedex, and intercostal nerve blocks. Standardization of operating room processes further contributes to improved outcome.
In the planning of surgery, several techniques are incorporated into the operation which contribute to postoperative care, early discharge, and reduced clinic follow-ups. For example, less invasive vein harvest decreases leg discomfort and the use of subcuticular skin closures negates the requirement to remove staples. The single mediastinal drainage suture is removed before discharge.
At the conclusion of the operation, postoperative management is kept as simple as possible. Limiting lines and drains as well as laboratory tests contribute to a feeling of well being both for the patient and family as well as the nursing staff. The plan for discharge the following day, if appropriate, is reinforced by allowing family visits early.
Nursing attitudes and expectations must also be modified. The shift in what is required for patients having off-pump revascularization versus on-pump can be facilitated by in-service training, and more importantly, a single contact point (the surgeon). Likewise, having nursing staff remove the pericardial drain, urinary catheter, and monitoring lines per protocol allows for accelerated patient care. Once the patient is ready for discharge home instructions are reinforced. Telephone numbers with easy access to a nurse clinician or physician assistant are mandatory. Follow-up phone calls by the nurse clinician the day after discharge are also very helpful.
The single most important aspect regarding creation of such a program that has been outlined is easy access to the surgeon by all components of the team as well as the patient. A caring team which shares the goals of OPCAB further facilitates the process.
Finally, it is indeed true that the postoperative care of patients undergoing myocardial revascularization is expectant and that such aggressive techniques should not be universally applied. However, many properly selected patients may be candidates for early discharge following uncomplicated OPCAB. Meticulous data regarding such programs must be maintained in order to analyze results and modify protocols accordingly. This will help to further stratify which patients are not candidates for outpatient CAB.
The evolution to such a program takes place over time. With resource limitations and an aging population it may not be possible to care for all patients requiring CAB in the same way as has been done in the past. The mentors in the field of cardiac surgery were, and are, visionaries who have allowed millions to benefit through their forward thinking. Like them, we must not be complacent, but rather accept that there is nothing outside reality, only our limitation to think outside the box.
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This article has been cited by other articles:
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  A. R. Srivastava, A. Banerjee, D. K. Tempe, B. Mishra, V. Muppiri, S. Narang, H. Singh, and S. Virmani A comprehensive approach to fast tracking in cardiac surgery: ambulatory low-risk open-heart surgery Eur J Cardiothorac Surg, June 1, 2008; 33(6): 955 - 960. [Abstract] [Full Text] [PDF]
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