Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery.

To determine if implementation of ultra-fast-track anesthetic (UFTA) technique facilitates operating room extubation in patients undergoing off-pump coronary artery bypass graft (CABG) surgery. Retrospective review. Referral center for cardiovascular surgery at a university hospital. Thirty-seven patients undergoing off-pump CABG surgery. Two groups represented UFTA (n = 10) and standard anesthetic (controls, n = 27) techniques. Anesthesia was conducted with propofol, remifentanil, vecuronium, and thoracic epidural analgesia in the UFTA group and thiopental, fentanyl, pancuronium, and isoflurane in the control group. Active temperature control was an integral part of the UFTA technique but not the standard technique. The active temperature control included intravenous fluid warmer, prewarmed skin preparation, humidified inspired gases, a circulating water warming blanket, and a forced-air warmer, along with the maintenance of the operating room temperature at 24 degrees C. The control group was managed with an intravenous fluid warmer, and the ambient temperature remained constant (20 degrees C). Patients who did not satisfy extubation criteria within 30 minutes from the end of surgery were sedated and transferred to the intensive care unit (ICU). All patients in the UFTA group and 2 in the control group were extubated in the operating room immediately after surgery. None of the patients required reintubation. There was no significant difference in postextubation PaO(2) and PaCO(2) between the groups. Nasopharyngeal temperature decreased from 36.7 +/- 0.4 degrees C to 36.4 +/- 0.3 degrees C in the UFTA group and from 36.6 +/- 0.5 degrees C to 35.6 +/- 0.4 degrees C in the control group (p < 0.0001). Bradycardia occurred significantly more often in the UFTA group but there was no difference in episodes of hypotension. There were no perioperative deaths. Patients who were extubated in the operating room required lower nurse-to-patient acuity ratio (1:2) in the ICU. No difference was found in ICU and hospital length of stay. Implementation of UFTA technique provided adequate hemodynamic control and facilitated operating room extubation in all patients. The impact of UFTA on earlier patient discharge and actual cost savings within a fully integrated post-cardiac surgery unit requires further evaluation.

Djaiani GN ，Ali M ，Heinrich L ，Bruce J ，Carroll J ，Karski J ，Cusimano RJ ，Cheng DC ... -  《JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA》

A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery.

To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery. Prospective, randomized, controlled clinical trial. Referral center for cardiothoracic surgery at a university hospital. Patients (n = 24) undergoing first-time elective CABG surgery. Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 microg/kg bolus followed by 0.25 to 1 microg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 microg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled. Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 +/- 82 minutes and 258 +/- 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 +/- 3 mg in the RITM group and 16 +/- 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO(2) and PaCO(2) after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups. Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation.

Bowler I ，Djaiani G ，Abel R ，Pugh S ，Dunne J ，Hall J ... -  《-》

[Operating room extubation (ultra fast-track anesthesia) in patients undergoing on-pump and off-pump cardiac surgery].

Borracci RA ，Dayán R ，Rubio M ，Axelrud G ，Ochoa G ，Rodríguez LD ... -  《-》

Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia.

Hemmerling TM ，Prieto I ，Choinière JL ，Basile F ，Fortier JD ... -  《Canadian Journal of Anesthesia-Journal canadien d anesthesie》

Extubation time, hemodynamic stability, and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal antiinflammatory drugs with propofol for perioperative and postoperativ

Maddali MM ，Kurian E ，Fahr J 《-》