Fast tracking in adult cardiac surgery at Pakistan Institute of Medical Sciences.

BACKGROUND: Early extubation after cardiac operation is an important aspect of fast-track cardiac anaesthesia. The length of stay in ICU limits utilisation of operation theatre in cardiac surgery. Increasing cost, limited resources, and newer surgical strategies have stimulated effectiveness of all routines in cardiac surgery, anaesthesia, and intensive care. Aim of this study was to determine the feasibility of fast-tracking in adult cardiac surgery and its effects on post operative recovery in our setup. METHODS: This descriptive study was conducted over 14 months between 16th Jul 2007 to 16th Sep 2008. All the open heart cases were included unless absolute contraindications were there. We applied the rapid recovery protocol adopted from Oslo Hospital Norway in an attempt to achieve fast-tracking in our setup. RESULTS: Two-hundred-seventy-four consecutive cases out of 400 operated cases were included in this study. Mean age was 47.69 +/- 15.11 years, 27.7% were females, 5.8% were emergency cases. 5.1% were COPD, 11.1% were atrial fibrillation, and 6.9% were NYHA class-III cases. CABG was done in 66.1% cases and mean CPB-time was 75.92 +/- 16.20 min. Mean Ventilation-time was 4.47 +/- 4.48 hrs, 86% patients were fast-tracked to be extubated within 6 hours, and 85.4% patients remained free of post-op complications. Six (2.2%) re-intubatlions, 2.6% arrhythmias, 6.6% pleural effusions and 2.2% consolidation were observed post-operatively. Mean ICU stay was 2.49 +/- 0.95 days and in-hospital mortality was 2.2%. CONCLUSION: Fast-tracking with extubation within 6 hours is feasible approach which minimises the post-operative complications significantly in adult cardiac surgical patients.

Off pump coronary artery surgery and intraoperative safety-experience at AFIC/NIHD, Rawalpindi.

BACKGROUND: Coronary Artery Bypass Grafting (CABG) with cardiopulmonary bypass (CPB) on one hand allows controlled haemodynamics with superior graft quality while on the other hand carries inherent risks of CPB which has renewed interest in Off-pump coronary artery bypass (OPCAB). Haemodynamic instability and intraoperative dysrythmias are major procedural complications of OPCAB, threatening conversion to emergency on-pump surgery. The purpose of this study was to compare intraoperative dysrythmias and inotropic use for haemodynamic stabilization during OPCAB surgery against conventional CABG. METHODS: Consecutive CABG cases operated between 1st June 2003 and 31st May 2006 were included while conversions were excluded. Primary end points were analyzed using chi square and t test and values described in percentages, means and probability (p value). RESULTS: Six hundred and eighty-four cases were divided in group-A (on-pump, n = 574) and B (OPCAB, n = 97). Conversion rate was 11.8%. Intraoperative dysrythmias (A, 3.5%, B, 15%, p < 0.0001) and use of inotropic support was higher in group-B (A, 15.3%, B, 30.3%, p < 0.0001). Actual mortality in group-B was higher than the predictive value (A, 3.8%, B, 3.6%, Predictive value 3-5% and 0-3% respectively). CONCLUSION: OPCAB leads to higher frequency of dysrythmias and inotropic use intraoperatively, highlighting lower procedural safety over conventional CABG.

Modified ultrafiltration: role in adult cardiac surgical haemostasis.

BACKGROUND: During cardiac surgery, cardiopulmonary bypass (CPB) leads to haemodilutional anaemia and activation of inflammatory mediators, affecting haemostasis. Modified Ultrafiltration (MUF) is being increasingly favoured for haemoconcentration without blood transfusion and reducing post operative bleeding. METHODS: Aim of this study was to record the impact of modified ultrafiltration on haemoconcentration and postoperative bleeding during adult cardiac surgery. This randomized control trial included 100 patients, divided into 2 groups; MUF and control group. Serial blood samples were drawn to evaluate haematological indices. Postoperative chest drainage was recorded for 24 hours. Results were expressed in terms of percentages, means and p value (p < 0.05 was taken as significant). RESULTS: Four patients were excluded and 96 patients were analyzed (MUF n = 50, control n = 46). According to American society of anaesthetist (ASA) classification, MUF group was higher risk group (p = 0.02) with longer extracorporeal perfusion time (p < 0.001). Haemoconcentration was successfully achieved in MUF group (final haemoglobin = 10.7 +/- 1.25, haematocrit = 33 +/- 3.64%, p < 0.001) with lower blood loss (MUF = 395 +/- 153 ml, control = 755 +/- 435 ml, p < 0.001) and transfusion requirement (p < 0.001). Re-exploration rate was 4% and 6.5% in MUF and control group respectively (p = 0.57). Mortality in both groups was comparable (MUF = 4%, control = 4.3%, p = 0.94). CONCLUSIONS: Modified ultrafiltration is a safe procedure which successfully achieves haemoconcentration, lowers blood loss and transfusion requirement after cardiac surgery in adult population.