Patient selection and anesthetic management for early extubation and hospital discharge: CABG

Three model systems have been described that may facilitate an increase in the numbers of patients passing through the hospital within the resource allocation available: (1) early fast-track extubation, < 3 hours after surgery, (2) planned intensive care unit discharge < 18 hours, and (3) early hospital discharge < 5 days. Thus far, studies have not clearly identified patient group or risk demonstrating a need for prolonged intubation or delayed intensive care unit and hospital length of stay. It thus appears appropriate to suggest that all patients be considered suitable for early extubation, mobilization, and hospital discharge. An increase in the proportion of patients eligible for a more rapid, but safe, progression through their operative procedures may be facilitated by pharmacologic intervention or alteration in anesthetic technique. Prevention of adverse perioperative myocardial outcome by inhibition of stress responses and careful control of intraoperative cardiovascular variables is most easily achieved by high thoracic (C7-T1) epidural conduction block or by a high-dose opioid anesthetic technique using remifentanil. The ultrashort action of remifentanil facilitates the ability to plan and control the period of recovery of spontaneous ventilation and extubation while providing profound reduction of intraoperative stress responses and hemodynamic stability. Safe extubation requires that the patient be alert and cooperative, be hemodynamically stable and warm, is not bleeding, and has adequate respiratory function. Interventions with anti-inflammatory and hemostatic agents such as the serine protease inhibitor aprotinin or with corticosteroids can have a major impact on achieving the criteria needed to ensure rapid discharge from the intensive care unit.