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Coronary artery bypass grafting "on pump": role of three-day discharge
R A Ott1, D E Gutfinger, M P Miller
1Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange 92668, USA.
Insights
A rapid-recovery protocol enables safe, same-day discharge for select coronary artery bypass grafting patients. This approach, focusing on early recovery milestones, offers a viable option for minimizing hospital stays in carefully chosen individuals.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Critical Care Medicine
Background:
- Growing emphasis on off-pump coronary artery bypass grafting (CABG) to reduce cardiopulmonary bypass (CPB) related morbidity and hospital stay.
- Investigating a rapid-recovery protocol for on-pump CABG to achieve discharge times comparable to off-pump procedures.
Purpose of the Study:
- To evaluate the feasibility and safety of a rapid-recovery protocol for on-pump CABG patients.
- To identify criteria for early hospital discharge (within 3 days) after on-pump CABG.
Main Methods:
- Retrospective review of 104 consecutive on-pump isolated CABG patients.
- Application of a rapid-recovery protocol including reduced CPB time, early extubation, perioperative corticosteroids and thyroid hormone, and aggressive diuresis.
- Defined criteria for 3-day discharge: ambulation without assistance, normal bowel function, and absence of atrial fibrillation at 72 hours postoperatively.
Main Results:
- Average postoperative length of stay was 4.8 days.
- 29% of patients (30/102 survivors) were discharged within 3 days (Group 1).
- Group 1 patients were younger with fewer comorbidities, experiencing fewer complications and lower readmission rates compared to Group 2 (discharged after 3 days).
Conclusions:
- A rapid-recovery protocol can facilitate safe 3-day postoperative discharge for selected on-pump CABG patients.
- Patients with minimal comorbid conditions are ideal candidates for this early discharge strategy.
- This protocol demonstrates the potential to shorten hospital stays without compromising patient safety.
Background:
A new emphasis has been directed toward "off-pump" coronary artery bypass grafting to avoid the morbidity of cardiopulmonary bypass and further reduce the postoperative hospital length of stay. With the intent of achieving a hospital discharge for "on-pump" coronary artery bypass grafting procedures comparable with the same procedures "off pump," we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day.
Methods:
The cases of 104 consecutive patients who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass were retrospectively reviewed. A rapid-recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthesia protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early extubation as well as a mild state of negative fluid balance and to ensure absence of postoperative bleeding and a safe transfer from the intensive care unit to a monitored floor. On the second postoperative day, chest drains were discontinued, and aggressive ambulation therapy was instituted. If at 72 hours postoperatively the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge home was planned.
Results:
The 30-day mortality rate for the entire group was 1.9%. The average postoperative hospital length of stay for the entire series was 4.8 +/- 2.4 days. Of the 102 survivors, 30 patients (29%) were discharged within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Patients in group 1 were younger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of an intraaortic balloon pump preoperatively (13% versus 35%). Group 1 patients also had almost no complications and a lower readmission rate (3.3% versus 6.9%).
Conclusions:
With the application of a rapid-recovery protocol to patients undergoing "on-pump" coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe for patients who have minimal comorbid conditions.