A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial.

INTRODUCTION: Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end-points in adult patients after elective cardiac surgery. METHODS: In a prospective, single blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new onset cardiac arrhythmia, low cardiac output syndrome, need for cardio-pulmonary resuscitation, stroke, acute renal failure, and death. RESULTS: Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P < 0.001). Median length of stay in PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P < 0.001). Of the adverse events examined, only the incidence of new onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups. CONCLUSIONS: Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step down unit, without compromising patient safety. TRIAL REGISTRATION: ISRCTN71768341. Registered 11 March 2014.

The incidence of intraoperative awareness in cardiac surgery fast-track treatment.

OBJECTIVE: To determine the occurrence of intraoperative awareness with recall in cardiac surgery patients undergoing fast-track anesthetic management in a direct-admission postanesthetic care unit. DESIGN: Prospective. SETTING: University-affiliated heart center. PARTICIPANTS: Five hundred thirty-four patients undergoing fast-track anesthesia. INTERVENTIONS: Using a structured interview process as part of the quality-assurance program. METHODS AND MAIN RESULTS: All fast-track patients during an 8-month period were entered into the study at a university hospital. Each patient was interviewed by research staff with the same standard set of questions within the first 24 hours of surgery. Follow-up interviews were performed on day 3 or 4 as well as on day 6 or 7 postsurgery. Awareness was defined by the presence of explicit memory of any event from the induction of anesthesia to the recovery of consciousness in the postanesthetic care unit (PACU). A final study population of 514 patients was evaluated. None of the answers given by any patient during any of the 3 interviews indicated intraoperative awareness, with the exception of one 54-year-old male patient. Most likely, this potential awareness did not take place during the operation but was caused by inadequate awakening in the PACU. CONCLUSION: Therefore, the authors conclude that, with respect to intraoperative awareness, the "Leipzig Fast-Track Concept" with the use of ultra-short-acting opioids should be considered as a safe method of management of patients undergoing a wide variety of cardiac operations.