Con

There is no definitive randomized controlled trial regarding ultra-fast-track anesthesia in cardiac surgery. Likewise, there is no solid meta-analysis that settles this debate. In fact, the definition of early extubation is incredibly inconsistent in the fast-track anesthesia literature. Some studies quote an 8-hour duration of intubation as a fast-track anesthetic, whereas other intensive care units would consider this postoperative respiratory failure in a stable uncomplicated patient. The primary outcomes promoted by the fast-track anesthesia and ultra-fast-track studies are length of stay in the intensive care unit, length of stay in the hospital, and duration of mechanical support measured in hours^1,2; however, these are not clinically significant outcomes. Outside the realm of highly scrutinized and efficiently run clinical trials, discharge from the intensive care unit or hospital is frequently delayed by nonclinical factors such as bed availability or nursing constraints. This discussion will point out the problems with ultra-fast-track anesthesia from both a patient safety and pragmatic viewpoint.

First is the concern about patient safety. The rush to extubate cardiac surgery patients in the operating room can lead to disaster. The dangers of ultra-fast-track extubation are numerous and will be addressed below. Some of the potential serious risks that ultra-fast-track anesthesia in cardiac surgery can lead to include inadequate pain control in a semiconscious patient, unrecognized bleeding that is difficult to diagnose leading to tamponade, hypoxemia leading to myocardial dysfunction, transfusion of procoagulant factors (fresh frozen plasma, platelets, cryoprecipitate, activated factor 7) rather than surgically reexploring the patient, and failure of dedicated staff to observe the patient as they recover from general anesthesia. All these issues can convert a low-risk cardiac surgery patient into an extremely unstable tenuous patient.

Inadequate pain control after cardiac surgery can lead to increased catecholamine release, which causes a hyperdynamic state. This hyperdynamic state generates a dangerous strain on fresh suture lines, as well as increases the risk of catastrophic bleeding, arrhythmias, and myocardial ischemia. Unlike intrathecal morphine and cesarean sections, the dose–response curve of narcotics to minimize hemodynamic effects of sternotomy while maximizing postoperative ventilation has not been worked out. This poses a significant challenge to cardiac anesthesiologists. Patients that are extubated in the operating room are frequently transported directly to the intensive care unit still under the effects of volatile anesthetics, benzodiazepines, and neuromuscular blockade. In the fresh postoperative cardiac surgery patient without a secured airway, any additional narcotic pain medicine further decreases respiratory drive leading to hypercarbia and hypoxemia that can frequently affect cardiac function in the postoperative cardiac surgery patient. Alternatives to intravenous narcotic pain medicine in cardiac surgery are controversial. In the United States, use of thoracic epidural analgesia for cardiopulmonary bypass has not been routinely accepted nor proven to provide a significant benefit over the risks involved. All these risks to the patient can be minimized when the patient is transferred to the intensive care unit where, the effects of volatile anesthetics can wear off. During this recovery phase, the patient receives a short course of positive pressure ventilation that allows the postoperative physician and nurse to aggressively titrate narcotic pain medicine while not risking further atelectasis and hypoventilation.

Unrecognized surgical bleeding is not an uncommon occurrence after on pump cardiac surgery. Postoperative hemorrhage due to an uncorrected coagulopathy or an unrecognized/untreated surgical bleed becomes evident within the first hours after surgery. Frequently, this is not evident in the operating room, and thus could easily be missed in a patient undergoing ultra-fast-track anesthesia. As blood accumulates in the chest the hemodynamic consequences can be grave. Often the first response of cardiac surgeons is to transfuse procoagulant blood products despite often normal laboratory values. This increased rate of transfusion in patients that are hemorrhaging after cardiac surgery contributes to increasing patients’ mortality after cardiac surgery.^3,4 Reintubating a recent postoperative patient with tamponade physiology is extremely dangerous. This should only be done by physicians with expertise in caring for unstable cardiac surgery patients. If the postoperative patient becomes hemodynamically unstable and he or she is not responding to fluids, inotropes, or vasopressors then a transesophageal echocardiography (TEE) can be performed easily in the intubated patient. A postoperative rescue TEE carries a high sensitivity, specificity, and interrater reliability for diagnosing the cause of hemodynamic instability when compared to filling pressures and hemodynamic measurements. ⁵ A cardiac anesthesiologist, in a matter of minutes, can rule in or rule out diagnosis that may push the surgeon for immediate reexploration due to tamponade. The TEE exam may also reveal a diagnosis that is very difficult to make without the assistance of TEE, such as systolic anterior motion of the mitral valve after mitral valve repair, right ventricular dysfunction, isolated clot behind the left atrium, or takotsubo cardiomyopathy. All of these can be life threatening, and require special treatment. If the patient has already been extubated, the diagnosis will be delayed putting the patient at undue risk in the immediate postoperative phase. ⁶ To be very clear, I am not advocating sedating a patient recovering from anesthesia to wait a certain period of time prior to extubation. I am advocating transferring a patient to the intensive care unit, intubated, recovering from anesthesia, while aggressively treating pain, and closely watching chest tube output and hemodynamic improvement as the patient recovers from volatile anesthesia.

Most intensive care units that care for post–cardiac surgery patients do not benefit from the expertise provided by cardiac anesthesiologists, anesthesia trained intensivists, or postanesthesia care unit nurses. ⁷ The converse is true as well; postanesthesia care unit nurses rarely see cardiac surgery patients and in general lack expertise in recovering these patients extubated in the operating room. ⁸ Intensive care unit nurses, cardiologists, cardiac surgeons, and nonanethesia intensivists have little to no education in monitoring patients recovering from general anesthesia. For an anesthesiologist evaluating a patient after surgery and deciphering the causes of a slow wake-up becomes second nature. Determining the difference between tachypnea caused by residual neuromuscular blockade, versus anxiety, versus splinting from pain is extremely foreign to the nonanesthesiologist. A frequent cause of reintubation in the intensive care unit after early extubation in the operating room is over titration of narcotics. Unfortunately in the United States, because of busy operating room schedules, unfavorable intensive care unit versus operating room reimbursement, and antiquated traditions of surgeons caring for their postoperative patients, anesthesiologists are infrequently involved in caring for patients in the intensive care unit. The devoted one-on-one care that is provided in the cardiac operating room by the anesthesiologist is not maintained in the early postoperative care of the cardiac surgery patient.

Finally, the economic argument is multifactorial and needs to be addressed in an unbiased fashion. The question to be answered is the following: Does extubation in the operating room provide the same care while conserving valuable resources when compared with the care of the patient extubated within 3 to 4 hours after surgery, not 12 to 24 hours after surgery? Operating room charges are assessed in minutes rather than intensive care unit costs, which are billed in hours. Therefore, any additional time spent in the operating room waiting for a patient to recover from anesthesia may add significant cost and may be comparable to an extra 2 hours in the intensive care unit. Expensive short acting anesthetic drugs also need to be considered in the cost analysis and the cost savings should be evaluated over long term so that ultra-fast-track patients who had postoperative hemorrhage and require reexploration can be accounted for. ⁸

In summary, ultra-fast-track anesthesia for cardiac surgery introduces risks to the patient that may be mitigated by transferring patients to the intensive care unit with a secure airway. These risks include poorly controlled pain leading to catecholamine surges that result in arrhythmias, strain on fresh suture lines, and potentially myocardial ischemia. On the converse side, the patients frequently require titration of potent narcotic pain medicine that can lead to hypoxemia and hypercarbia in the immediate postoperative stage that can lead to myocardial dysfunction. Finally, the economic benefit of ultra-fast-track anesthesia is questionable and until there is a complete cost analysis that includes operating room time, cost of ultra-fast-track medications, and compares the cost of reintubation and delayed surgical operation it is difficult to weigh in on the cost benefit advocated in the literature. I do believe that ultra-fast-track anesthesia, when done by a cardiac anesthesiologist, in the correct patient population with intense bedside care can be done safely; however, I do not see a huge benefit to this practice.