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Early tracheal extubation and UK fast track cardiac surgery: are we missing the point?
- Richard R Marks, Alison D Parnell, Mario Shekar (18 February 2008)
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Richard R Marks, Consultant Anaesthetist South Yorkshire Cardiothoracic Unit, Alison D Parnell, Mario Shekar
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Editor, we read with interest the editorial by Hemmerling TM and Carli F on epidural anaesthesia for cardiac surgery (1). We are grateful to the authors for highlighting this important subject. Having recently completed a survey of fast track activity in our Cardiac Units we would like to make a number of points relevant to UK clinical practice. Fundamental to any discussions relating to ‘fast track’ cardiac surgery is the arrival at a definition which is clinically meaningful. The authors define this as ‘tracheal extubation within 8h after cardiac surgery’. An extubation time of 8 hours would not be considered particularly fast by UK standards. In itself it would not imply fast track progress. Whilst there is no agreed definition of fast track surgery, clearly some emphasis is placed on the speed of extubation. The authors express some disappointment that greater clinical benefits have not resulted from a fast track approach. It should be appreciated that outcome from elective coronary surgery is already excellent and it is asking a lot of the fast track process to impact significantly on this. Our major objectives for a fast track approach are therefore cost saving through utilising resources more efficiently. From an economic perspective, to be of benefit, ‘fast track’ must be translated to either a reduction in intensive care utilisation or a reduced hospital stay. Within reasonable limits, there is no absolute relationship between tracheal extubation time and success as measured by either of these end points. Our working definition of fast track is therefore ‘the progression from 1:1 nursing to 1:2 nursing on the day of surgery’ avoiding intensive care unit admission (2). This is equally achievable from a tracheal extubation time of 5 minutes or 5 hours. Tracheal extubation time was not isolated as an independent predictor of fast track in our unit in a multivariate analysis of 760 cases (2). Recently, using our more encompassing definition, we have identified 46% of UK cardiac units as having an established fast track pathway (3). The existence of significantly reduced cancellation rates in these units (see TableTable.ppt) implies that this may be a more meaningful definition than measuring extubation time in UK practice (see Table "Insert Link"). The authors state that thoracic epidural analgesia has not been used ‘to its full potential to implement immediate tracheal extubation’. ‘Ultra -fast track cardiac anaesthesia’ referred to by the authors is again related to extubation time. Unfortunately, until we are clear on what constitutes ‘fast track’, simply attempting to reduce tracheal extubation time to the absolute minimum is an over simplification of what is needed. For example, a significant number of UK cardiac units still do not have separate high dependency facilities, and even if tracheal extubation following surgery is instantaneous, there may be no place to care for the patient other than the intensive care unit until they are fit for ward care. Equally a shortage of ward or high dependency beds is commonly sited and may become rate limiting. Early tracheal extubation itself is not without hazards and the concept of an ‘optimum’ extubation time or ‘extubation window’ has previously been proposed (4). Setting aside the role of early tracheal extubation in fast track pathways, we are not convinced of the necessity of thoracic epidural analgesia (TEA) for early tracheal extubation. Work from our unit using the now outlawed parecoxib showed even in our placebo control group using a morphine patient controlled analgesia (PCA) pump, a median extubation time of 42 minutes with a median morphine usage of 3(0-12) mg in the first 6 hours post extubation (5). In a larger study, the benefits of TEA in comparison to morphine PCA, with a median extubation time around 3-4 hours, was at best slight6. The authors express disappointment about the failure of thoracic epidurals to expedite fast track, but in view of the exhaustive table of requirements referred to in their article it is not surprising that epidural analgesia alone can not make a difference. The article concludes that TEA is ‘an important trigger of a novel chain reaction’. Whilst we do not doubt its role, in the absence of prospective evidence demonstrating a clear clinical benefit in facilitating ‘fast track’, ‘ultra fast track’ or whatever end point we chose to define, its importance should not in our opinion be overstated. Further studies on fast track cardiac surgery are essential, but first we must agree on its objectives relevant to a given healthcare system. Agreement on a better measure than extubation time alone is urgently required. AD Parnell M Shekar RRD Marks* Sheffield UK E-mail: richard.marks@sth.nhs.uk 1. Hemmerling TM, Carli F, Noiseux N. Thoracic epidural anaesthesia for cardiac surgery: are we missing the point? Br J Anaesth 2008: 100:3-5 2. Syed SK, Graham J, Thompson H, Woodward DK, Marks RRD. An analysis of early complications in fast track cardiac surgery patients. Br J Anaesth 2007: 98:288-9 3. Parnell AD, MacBryde G, Sanders C, Marks RRD. A study of fast track activity in UK cardiac units. Br JAnaesth (abstract in press January 2008) 4. Wynands JE. Pro: Early endotracheal extubation in patients following coronary artery surgery. J Cardiothorac Vasc Anesth 1992: 6:488- 93 5. Khalil MW, Chaterjee A, Macbryde G, Marks RRD Single dose parecoxib significantly improves ventilatory function in early extubation cardiac surgery. Br J Anaesth 2006: 96: 171-8 6. Preistly MC, Cope L, Halliwell R, Gibson P, Chard RB, Skinner M, Klineberg PL. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Anesth Analg 2002: 94: 275-82 Conflict of Interest:None declared |
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