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The effect of fast-tracking on neurological complications post-cardiopulmonary bypass
1Lehigh Valley Hospital, Allentown, Pennsylvania 18105, USA.
Insights
Fast-tracking coronary artery bypass grafting (CABG) did not increase postoperative neurological complications in this study. Maintaining adequate oxygen saturation during cardiopulmonary bypass (CPB) may mitigate risks associated with lighter anesthesia.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Neurology
Background:
- The trend towards shorter hospital stays has led to 'fast-tracking' non-emergency coronary artery bypass grafting (CABG).
- This approach may involve lighter anesthesia during cardiopulmonary bypass (CPB), potentially increasing cerebral metabolism and risk of neurological deficit.
- Current fast-tracking protocols aim to maintain mean arterial pressure above 65 mmHg during CPB.
Purpose of the Study:
- To evaluate the association between intraoperative mean arterial pressure during CPB and postoperative neurological complications in fast-tracked CABG patients.
- To determine if 'fast-tracking' anesthetic regimens increase the risk of neurological deficits after non-emergency CABG.
Main Methods:
- Retrospective analysis of 200 patients undergoing non-emergency CABG.
- Patients were divided into two groups based on mean arterial pressure during CPB: Group 1 (>65 mmHg) and Group 2 (<65 mmHg).
- Patients were matched for surgeon, procedure, and CPB time.
Main Results:
- Both groups (n=100 each) showed a 2% incidence of postoperative neurological complications (delirium, coma, transient stroke).
- In Group 1, two patients had complications, both with pre-existing cerebrovascular disease.
- In Group 2, two patients had complications, one with pre-existing cerebrovascular disease.
Conclusions:
- This study found no increased risk of postoperative neurological complications with fast-tracked CABG when mean arterial pressure was maintained above 65 mmHg during CPB.
- Maintaining mean venous oxygen saturation above 70% during CPB might be a protective factor.
- Further research with more specific testing is needed to definitively rule out negative postoperative effects of fast-tracking.
Abstract:
With the push to get patients through the system in five days, most patients undergoing nonemergency coronary artery bypass grafting (CABG) are being "fast-tracked'. Using this anaesthetic regimen appears to keep patients less anaesthetized (light) during cardiopulmonary bypass (CPB) than when using our previous regimen. This is manifested by higher mean arterial pressures (maintained above 65 mmHg) during CPB. If patients are receiving less anaesthesia during CPB, they may have an increased cerebral metabolism. This could lead to decreased cerebral oxygenation with a resultant neurological deficit postoperatively. A retrospective analysis of 200 patients who underwent nonemergency CABG was conducted to evaluate postoperative neurological complications. The patients were matched by surgeon, procedure and CPB time. They were separated into two groups: group 1 had maintained mean arterial pressures greater than 65 mmHg on CPB (n = 100) and group 2 had pressures less than 65 mmHg (n = 100). Group 1 had two patients (2%) who exhibited neurological complications after CPB (delirium, continuous coma for at least 24 h) with both of these patients previously having noted cerebrovascular disease. Group 2 also had two patients (2%) with postoperative neurological complications (delirium, transient stroke) with one patient having cerebrovascular disease. From our study, we cannot say that fast-tracking increases the risk for postoperative neurological complications. This could be due to the fact that we maintained the mean venous oxygen saturation during CPB above 70%. More specific testing needs to be done to truly rule out any negative postoperative effect.