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On aging, fast-tracking, and derailment in CABG patients
Journal of
Cardiothoracic and Vascular Anesthesia AUGUST 1998
VOL 12, NO 4
EDITORIAL On Aging, Fast-Tracking, and Derailment in CABG Patients HANGES IN the economics of health care have fueled sometimes painful changes in the way that anesthesia is thought about and delivered to patients. The first round of change arrived in the 1980s, when it was learned that the Health Care Financing Administration and, subsequently, other thirdparty payers no longer wished to pay for elective inpatient surgical patients to spend the night before surgery in the hospital. Physicians and hospital administrators whimpered and whined to no avail, then eventually adjusted to the new paradigm and constructively revamped the entire process of preoperative evaluation. The 1990s have brought fu~l-Lereconomic pressures that might best be measured using the Richter scale, among which is a need to drastically reduce the cost of expensive surgery, such as coronary artery bypass grafting (CABG). In so doing, it has been learned that the most expensive parts of an elective CABG procedure are the intraoperative and intensive care unit (ICU) phases, which account for about 70% of the hospitalization costs.1 Gaining or retaining market share has pitted hospital against hospital, surgeon against surgeon, and other specialists against their peers in an effort to produce CABGs at the lowest safe cost. As a result, the concept of early extubation has been resurrected from the 1970s,2-4 when it did not gain wide acceptance. Cleverly, this rebirth in the 1990s has been dubbed "fast-tracking." In this issue, Lee et al5 retrospectively assessed their experience with early extubation in elderly CABG patients. Defining elderly as 70 years of age or older, they reported that 48% of elderly patients achieved endotracheal extubation within 8 hours of postoperative arrival in the ICU, compared w~th 59% of younger CABG patients. More than 40% of octagenarians achieved early extubation, and early extubation (without regard to age) was associated with a shorter hospital length of stay (LOS; 5.5 v 8.4 days) without a difference in ICU LOS. Unsurprisingly, elderly patients had a greater preoperative prevalence of congestive heart failure, prior stroke, lung disease, and peripheral vascular disease. To their credil, Lee et als included all comers in their analysis without regar:l to the urgency of surgery. They did not stratify their results by diagnosis-related group (DRG) category, so their hospital LOS numbers were slightly inflated to whatever degree the study population reflected DRG 106 (CABG with coronary angiography at the same admission), rather than DRG 107 (CABG only). The study of Lee et al5 was not designed to permit assessment of what caused patients to succeed or fail in the fast-track protocol. This raises questions about whether there were
C
particular patient-risk profiles that caused the surgeon or anesthesiologist to decide a priori that a patient was unsuitable for fast-tracking, thereby introducing bias, particularly if advanced age was one of the decision-guiding factors. The other possibility is that all patients were placed on the fast track unless something happened that led to "derailment," which appears to be a common clinical approach elsewhere. If the latter was the case, it would have been helpful to have established standard derailment criteria, which were probably rendered infeasible by the retrospective study design. The next logical step will be to perform a prospective comparison of fasttracking and slower tracking in elderly patients in a fashion analogous to what Cheng et al6 have provided for patients not selected by age. The work presented by Lee et al5 provides this author with an opportunity to reflect on the recent past and project some future needs as follows: Old people are not as old as they used to be. In the physiologic sense of aging, advances in diagnosis, treatment, and prevention of disease have led to a steady increase in life expectancy in developed nations. At least partly as a result of this change, CABG results in the elderly have advanced to vel2~ acceptable levels of morbidity and mortality, with the noteworthy exception of stroke as a complication.7,~ CABG patients are not as young as they used to be. The mean age of patients undergoing CABG has increased steadily from the low 50s in the 1970s to the mid-60s in the 1990s.9 Consequently, clinicians cannot expect to develop a successful clinical or economic change in the care of CABG patients without applying that change to the elderly. Why wasn't fast tracking embraced in the 1980s? The "slow-track" recovery from CABG, generally involving mechanical ventilation for 12 to 24 hours and an ICU stay of 24 to 48 hours, was developed in response to the cardiac surgical needs of the 1960s and 1970s. In the 1980s, significant advances in the technology of extracorporeal circulation, as well as in the pharmacology and delivery of myocardial protection, were put into practice; changes that largely enabled current successes with fast-tracking. Perhaps as a result of inertia, these advances were inadequately applied to anesthetic and early postoperative management in the 1980s, because high-dose opioid techniques mandating delayed extubation largely prevailed. Why did it take an economic upheaval for anesthesiologists to realize that this approach was no longer necessary?
Journal o f Cardiothoracic and Vascular Anesthesia, Vo[ 12, No 4 (August), 1998: pp 379-380
379
380
GLENN P. GRAVLEE
What further information is needed about fast-tracking? First, a generally accepted definition of fast-tracking is needed. Lee et al 5 arbitrarily defined it as extubation within 8 hours of ICU arrival, which seems to be a reasonable benchmark. Published definitions and approaches have ranged from extubation on the operating room table followed by a 2- to 4-hour stay in the postanesthesia recovery area and transfer to a stepdown unit, all the way to extubation within 12 hours and an ICU stay as long as 24 hours. 1°-14Because what is fast to some is slow to others, it becomes imperative to carefully assess the operative definition when reading about or discussing fast-tracking. As clinicians proceed along this "track," they must caution against the development of unnecessary risk. There is some evidence, for example, that sustained high-dose opioid analgesia reduces early postoperative ischemia. Additionally, common sense suggests the presence of some risk profile that precludes early
extubation, perhaps especially in the elderly. Future studies are needed to help identify those patients. Clinicians should also be cautious about embracing fast-tracking investigations that do not provide sufficient detail to assess the incidence of reintubation or delayed readmission to the ICU. Future studies must also continue to enlighten health care professionals about the cost savings and LOS implications of fast-tracking, because there is still debate about its economic efficacy. 15,16 Lee et al 5 have provided a good starting point, but much remains to be learned about fast-tracking in elderly C A B G patients.
Glenn P. Gravlee, MD Professor and Chair, Department of Anesthesiology Allegheny University Hospitals, Allegheny General Pittsburgh, PA
REFERENCES 1. Cheng DCH: Fast-track cardiac surgery: Economic implications in postoperative care. J Cardiothorac Vasc Anesth 12:72-79, 1998 2. Prakash O, Jonson B, Meij S: Criteria for early extubation after intracardiac surgery in adults. Anesth Analg 56:703-708, 1977 3. Klineberg PL, Geer RT, Hirsh RA: Early extubation after coronary artery bypass graft surgery. Crit Care Med 5:272-274, 1977 4. QuashaAL, Lobber N, Feeley TW: Postoperative respiratory care: A controlled trial of early and late extubation following coronary artery bypass grafting. Anesthesiology 52:135-141, 1980 5. Lee JH, Graber R, Popple CG, et al: Safety and efficacy of early extubation of elderly coronary bypass surgery patients. J Cardiothorac Vasc Anesth 12:381-384, 1998 6. Cheng DCH, Karski J, Peniston C: Morbidity outcome in early versus conventional tracheal extubation following coronary artery bypass grafting (CABG) surgery: A prospective randomized controlled trial. J Thorac Cardiovasc Surg 112:755-764, 1996 7. Acinapura AJ, Rose DM, Cunningham JN Jr, et al: Coronary artery bypass in septuagenarians. Analysis of mortality and morbidity. Circulation 78:I179-I184, 1988 (suppi I) 8. Utley JR, Leyland SA: Coronary artery bypass grafting in the octogenarian. J Thorac Cardiovasc Snrg 101:866-870, 1991 9. Edwards FH, Clark RE, Schwartz M: Coronary artery bypass
grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 57:12-19, 1994 10. London MJ, Shroyer LW, Jernigan V, et al: Fast-track cardiac surgery in a Department of Veterans Affairs patient population. Ann Thorac Surg 64:134-141, 1997 11. Chong JL, Grebenik C, Sinclair M: The effects of a cardiac surgical recovery area on the timing of extubation. J Cardiothorac Vasc Anesth 7:137-141, 1993 12. Westaby S, Pillai R, Parry A: Does modern cardiac surgery require conventional intensive care? Eur J Cardiothorac Surg 7:313318, 1993 13. Engelman RM, Rousou JA, Flack JE: Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 58:1742-1746, 1994 14. Cheng DCH, Karski J, Peniston C: Early tracheal extubation after coronary bypass grafting surgery reduces costs and improves resource use: A prospective randomized controlled trial. Anesthesiology 85:1300-1310, 1996 15. Cheng DCH: Pro: Early extubation after cardiac surgery decreases intensive care unit stay and cost. J Cardiothorac Vasc Anesth 9:460-464, 1995 16. Guenther CR: Con: Early extubation after cardiac surgery does not decrease intensive care unit stay and cost. J Cardiothorac Vasc Anesth 9:465-467, 1995
Cardiothoracic and Vascular Anesthesia AUGUST 1998
VOL 12, NO 4
EDITORIAL On Aging, Fast-Tracking, and Derailment in CABG Patients HANGES IN the economics of health care have fueled sometimes painful changes in the way that anesthesia is thought about and delivered to patients. The first round of change arrived in the 1980s, when it was learned that the Health Care Financing Administration and, subsequently, other thirdparty payers no longer wished to pay for elective inpatient surgical patients to spend the night before surgery in the hospital. Physicians and hospital administrators whimpered and whined to no avail, then eventually adjusted to the new paradigm and constructively revamped the entire process of preoperative evaluation. The 1990s have brought fu~l-Lereconomic pressures that might best be measured using the Richter scale, among which is a need to drastically reduce the cost of expensive surgery, such as coronary artery bypass grafting (CABG). In so doing, it has been learned that the most expensive parts of an elective CABG procedure are the intraoperative and intensive care unit (ICU) phases, which account for about 70% of the hospitalization costs.1 Gaining or retaining market share has pitted hospital against hospital, surgeon against surgeon, and other specialists against their peers in an effort to produce CABGs at the lowest safe cost. As a result, the concept of early extubation has been resurrected from the 1970s,2-4 when it did not gain wide acceptance. Cleverly, this rebirth in the 1990s has been dubbed "fast-tracking." In this issue, Lee et al5 retrospectively assessed their experience with early extubation in elderly CABG patients. Defining elderly as 70 years of age or older, they reported that 48% of elderly patients achieved endotracheal extubation within 8 hours of postoperative arrival in the ICU, compared w~th 59% of younger CABG patients. More than 40% of octagenarians achieved early extubation, and early extubation (without regard to age) was associated with a shorter hospital length of stay (LOS; 5.5 v 8.4 days) without a difference in ICU LOS. Unsurprisingly, elderly patients had a greater preoperative prevalence of congestive heart failure, prior stroke, lung disease, and peripheral vascular disease. To their credil, Lee et als included all comers in their analysis without regar:l to the urgency of surgery. They did not stratify their results by diagnosis-related group (DRG) category, so their hospital LOS numbers were slightly inflated to whatever degree the study population reflected DRG 106 (CABG with coronary angiography at the same admission), rather than DRG 107 (CABG only). The study of Lee et al5 was not designed to permit assessment of what caused patients to succeed or fail in the fast-track protocol. This raises questions about whether there were
C
particular patient-risk profiles that caused the surgeon or anesthesiologist to decide a priori that a patient was unsuitable for fast-tracking, thereby introducing bias, particularly if advanced age was one of the decision-guiding factors. The other possibility is that all patients were placed on the fast track unless something happened that led to "derailment," which appears to be a common clinical approach elsewhere. If the latter was the case, it would have been helpful to have established standard derailment criteria, which were probably rendered infeasible by the retrospective study design. The next logical step will be to perform a prospective comparison of fasttracking and slower tracking in elderly patients in a fashion analogous to what Cheng et al6 have provided for patients not selected by age. The work presented by Lee et al5 provides this author with an opportunity to reflect on the recent past and project some future needs as follows: Old people are not as old as they used to be. In the physiologic sense of aging, advances in diagnosis, treatment, and prevention of disease have led to a steady increase in life expectancy in developed nations. At least partly as a result of this change, CABG results in the elderly have advanced to vel2~ acceptable levels of morbidity and mortality, with the noteworthy exception of stroke as a complication.7,~ CABG patients are not as young as they used to be. The mean age of patients undergoing CABG has increased steadily from the low 50s in the 1970s to the mid-60s in the 1990s.9 Consequently, clinicians cannot expect to develop a successful clinical or economic change in the care of CABG patients without applying that change to the elderly. Why wasn't fast tracking embraced in the 1980s? The "slow-track" recovery from CABG, generally involving mechanical ventilation for 12 to 24 hours and an ICU stay of 24 to 48 hours, was developed in response to the cardiac surgical needs of the 1960s and 1970s. In the 1980s, significant advances in the technology of extracorporeal circulation, as well as in the pharmacology and delivery of myocardial protection, were put into practice; changes that largely enabled current successes with fast-tracking. Perhaps as a result of inertia, these advances were inadequately applied to anesthetic and early postoperative management in the 1980s, because high-dose opioid techniques mandating delayed extubation largely prevailed. Why did it take an economic upheaval for anesthesiologists to realize that this approach was no longer necessary?
Journal o f Cardiothoracic and Vascular Anesthesia, Vo[ 12, No 4 (August), 1998: pp 379-380
379
380
GLENN P. GRAVLEE
What further information is needed about fast-tracking? First, a generally accepted definition of fast-tracking is needed. Lee et al 5 arbitrarily defined it as extubation within 8 hours of ICU arrival, which seems to be a reasonable benchmark. Published definitions and approaches have ranged from extubation on the operating room table followed by a 2- to 4-hour stay in the postanesthesia recovery area and transfer to a stepdown unit, all the way to extubation within 12 hours and an ICU stay as long as 24 hours. 1°-14Because what is fast to some is slow to others, it becomes imperative to carefully assess the operative definition when reading about or discussing fast-tracking. As clinicians proceed along this "track," they must caution against the development of unnecessary risk. There is some evidence, for example, that sustained high-dose opioid analgesia reduces early postoperative ischemia. Additionally, common sense suggests the presence of some risk profile that precludes early
extubation, perhaps especially in the elderly. Future studies are needed to help identify those patients. Clinicians should also be cautious about embracing fast-tracking investigations that do not provide sufficient detail to assess the incidence of reintubation or delayed readmission to the ICU. Future studies must also continue to enlighten health care professionals about the cost savings and LOS implications of fast-tracking, because there is still debate about its economic efficacy. 15,16 Lee et al 5 have provided a good starting point, but much remains to be learned about fast-tracking in elderly C A B G patients.
Glenn P. Gravlee, MD Professor and Chair, Department of Anesthesiology Allegheny University Hospitals, Allegheny General Pittsburgh, PA
REFERENCES 1. Cheng DCH: Fast-track cardiac surgery: Economic implications in postoperative care. J Cardiothorac Vasc Anesth 12:72-79, 1998 2. Prakash O, Jonson B, Meij S: Criteria for early extubation after intracardiac surgery in adults. Anesth Analg 56:703-708, 1977 3. Klineberg PL, Geer RT, Hirsh RA: Early extubation after coronary artery bypass graft surgery. Crit Care Med 5:272-274, 1977 4. QuashaAL, Lobber N, Feeley TW: Postoperative respiratory care: A controlled trial of early and late extubation following coronary artery bypass grafting. Anesthesiology 52:135-141, 1980 5. Lee JH, Graber R, Popple CG, et al: Safety and efficacy of early extubation of elderly coronary bypass surgery patients. J Cardiothorac Vasc Anesth 12:381-384, 1998 6. Cheng DCH, Karski J, Peniston C: Morbidity outcome in early versus conventional tracheal extubation following coronary artery bypass grafting (CABG) surgery: A prospective randomized controlled trial. J Thorac Cardiovasc Surg 112:755-764, 1996 7. Acinapura AJ, Rose DM, Cunningham JN Jr, et al: Coronary artery bypass in septuagenarians. Analysis of mortality and morbidity. Circulation 78:I179-I184, 1988 (suppi I) 8. Utley JR, Leyland SA: Coronary artery bypass grafting in the octogenarian. J Thorac Cardiovasc Snrg 101:866-870, 1991 9. Edwards FH, Clark RE, Schwartz M: Coronary artery bypass
grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 57:12-19, 1994 10. London MJ, Shroyer LW, Jernigan V, et al: Fast-track cardiac surgery in a Department of Veterans Affairs patient population. Ann Thorac Surg 64:134-141, 1997 11. Chong JL, Grebenik C, Sinclair M: The effects of a cardiac surgical recovery area on the timing of extubation. J Cardiothorac Vasc Anesth 7:137-141, 1993 12. Westaby S, Pillai R, Parry A: Does modern cardiac surgery require conventional intensive care? Eur J Cardiothorac Surg 7:313318, 1993 13. Engelman RM, Rousou JA, Flack JE: Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 58:1742-1746, 1994 14. Cheng DCH, Karski J, Peniston C: Early tracheal extubation after coronary bypass grafting surgery reduces costs and improves resource use: A prospective randomized controlled trial. Anesthesiology 85:1300-1310, 1996 15. Cheng DCH: Pro: Early extubation after cardiac surgery decreases intensive care unit stay and cost. J Cardiothorac Vasc Anesth 9:460-464, 1995 16. Guenther CR: Con: Early extubation after cardiac surgery does not decrease intensive care unit stay and cost. J Cardiothorac Vasc Anesth 9:465-467, 1995