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Rapid recovery after coronary artery bypass grafting: is the elderly patient eligible?
R A Ott1, D E Gutfinger, M P Miller
1Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange, California 92668, USA.
Insights
Elderly patients undergoing coronary artery bypass grafting (CABG) can safely benefit from rapid recovery protocols. While younger patients are discharged sooner, the protocol improves recovery for all age groups, including older adults.
Area of Science:
- Cardiovascular Surgery
- Geriatric Medicine
- Anesthesiology
Background:
- Rapid recovery protocols (RRPs) are established for younger patients post-coronary artery bypass grafting (CABG).
- Validation of RRPs in elderly populations is limited, with some centers hesitant about early discharge for older adults.
- Elderly patients often have comorbidities that may complicate recovery.
Purpose of the Study:
- To evaluate the efficacy and safety of RRPs in elderly patients undergoing isolated CABG.
- To compare outcomes between elderly and younger patient groups receiving RRPs.
- To assess the feasibility of early hospital discharge for elderly CABG patients.
Main Methods:
- Retrospective comparison of 167 elderly patients (>=70 years) and 152 younger patients (<70 years) undergoing isolated CABG.
- All patients received an RRP including early extubation, reduced cardiopulmonary bypass time, perioperative corticosteroids, and thyroid hormone.
- Protocol elements also included early management of atrial fibrillation, negative fluid balance, bowel function, mobilization, and intraaortic balloon pump use.
Main Results:
- No significant difference in 30-day mortality or postoperative complications between elderly (4.2%) and younger (3.3%) groups.
- 19% of elderly patients achieved discharge before the fifth postoperative day, compared to 48% of younger patients (p < 0.001).
- Elderly patients had a longer hospital stay (8.0 days) than younger patients (5.7 days; p < 0.01).
Conclusions:
- Rapid recovery protocols expedite recovery for all CABG patients, irrespective of age or comorbidities.
- Elderly patients are suitable candidates for RRPs, demonstrating comparable safety profiles to younger patients.
- While younger patients experience shorter hospital stays, RRPs offer benefits for older adults, challenging reluctance towards early discharge.
Background:
Rapid recovery protocols after coronary artery bypass grafting have been applied successfully to young patients with normal ventricular function. However, the success of such protocols when applied to the elderly population has not been thoroughly validated, and at some centers there is still reluctance in allowing elderly patients to be discharged early from the hospital.
Methods:
One hundred fifty-two consecutive younger patients (< 70 years) were compared retrospectively with 167 consecutive elderly patients (> or = 70 years) who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass. A rapid recovery protocol emphasizing an anesthetic protocol for early extubation, reduced cardiopulmonary bypass time, and perioperative administration of corticosteroids and thyroid hormone was applied to all patients. The protocol also emphasized early identification and management of postoperative atrial fibrillation, a proactive negative fluid balance, rapid return of bowel function, mobilization of the patient, and aggressive use of the intraaortic balloon pump preoperatively.
Results:
The 30-day mortality rate for the younger group of patients was 3.3% (Parsonnet risk 7.2 +/- 6.2), compared with 4.2% (Parsonnet risk, 17.7 +/- 6.8) for the elderly group of patients. There were no statistically significant differences in the 30-day mortality rates or postoperative complications between the elderly and younger patient groups. Rapid recovery with discharge before the fifth postoperative day was achieved in 19% of the elderly, in comparison with 48% of the younger patients (p < 0.001). The younger patients were discharged earlier after operation than the older patients (5.7 +/- 5.2 versus 8.0 +/- 8.5 days; p < 0.01).
Conclusions:
Application of the rapid recovery protocol helped expedite recovery for all patients regardless of age, acuity of illness, or associated conditions. Although younger patients had a significantly shorter postoperative length of hospital stay, older patients performed well and are suitable candidates for rapid recovery protocols.