Influence of Fast-Track Anesthetic Technique on Cardiovascular Infusions and Weight Gain Sandra L. Larson, CRNA, MS, Carrie H. Schimmel, CRNA, MS, Susan Shott, PhD, Philip B. Myers, MD, and Bryan K. Foy, MD Objective: To evaluate whether cardiac surgical patients receiving conventional versus fast-track anesthetic manage- ment are statistically significantly different with regard to cardiovascular drug infusions, weight gain, cardiac and pulmonary morbidity, length of intubation, and length of stay. Design: Retrospective, (partially) sequential, cohort de- sign. Setting: Surgical suite and intensive care unit (ICU) at a community hospital. Participants: Two hundred seven patients who presented for coronary artery bypass graft and/or cardiac valve replacement. Interventions: None Measurements and Main Results: Group comparisons of the seven individual cardiovascular drug infusions showed less frequent use in the fast-track patients for lidocaine (9% v 28%; p= 0.00046) only. However, the fast-track group received fewer combinations of cardiovascular drug infu- sions overall for the first 24-hour postoperative period (p < 0,0005). Hourly comparisons of inotropes showed significantly fewer combinations of dobutamine, norepineph- rine, and epinephrine for the first postoperative hour and for postoperative hours 7 through 12 (p < 0.01 for each hour). Fast-track patients had less postoperative weight gain for days 1 through 4 {p < 0.01 for each day), shorter length of ICU stay (p < 0.00005), and shorter total length of postopera- tive hospital stay (p = 0.0004). No differences were found with respect to myocardial infarction, death, pulmonary complications, rate of reintubation, or length of hospital stay once discharged from the ICU. Conclusions: Fast-track anesthetic management may be associated with decreased need for inotropic and antiarrhyth- mic drug infusions and decreased weight gain. Copyright © 1999 by W.B. Saunders Company KEY WORDS: cardiac anesthesia, cardiac surgery, fast-track, inotropic support, weight gain R ESEARCH showing the safety of early extubation in patients undergoing cardiac surgery has been available for more than 20 years.l-5 However, only recently has anesthesia for cardiac surgery undergone a rapid and widespread conver- sion from high dosages of opioids and overnight ventilatory support to significantly lower dosages and early extubation. This conversion was necessary to achieve fast-track recovery in cardiac surgical patients, established by cardiologists and cardiac surgeons in the early 1990s. 6-9 Fast-track protocols depend on a low-dose opioid anesthetic technique to expedite patient extubation and ambulation. 1° Fast-tracking is fueled in part by market forces demanding more cost-efficient quality care and to this end has achieved decreased hospital costs through reduced intensive care unit (ICU) and hospital stays.n-~s Controversy surrounding the wisdom of fast-track manage- ment 16 is subsiding as increasing research becomes available to support its safety and efficiency for a variety of cardiac surgical patients. For example, London et al I7,18 showed a lower rate of nosocomial pneumonia in a veterans population, and Johnson et all9 showed decreased atelectasis with early extubation in elective coronary artery bypass surgery (CABG) patients with normal left ventricular function. In a prospective randomized study, Cheng et al20 reported no increases in perioperative cardiac, respiratory, hemodynamic, or sympathoadrenal morbid- ity in early versus conventional extubation. Ott et a121confirmed that rapid-recovery protocols can be successfully applied to elderly patients (->70 years) undergoing CABG. Reyes et a115 found a greater incidence of reintubation in patients extubated From the Provena Saint Joseph Medical Center, Joliet, IL. Supported in part by Provena Saint Joseph Medical Center Founda- tion, Joliet, IL. Address reprint requests to Sandra Larson, CRNA, MS, 2256 Ridgewood Rd, Lisle, IL 60532. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1304-0009510.00/0 early (within 7 to ll hours postoperatively); however, patients in both groups received a moderately high-opioid anesthetic technique. Engelman et al9 reported the benefit of less weight gain in fast-track patients and attributed this to the use of methylprednisolone before cardiopulmonary bypass (CPB). Engelman et al9 also reported no group differences in the use of inotropic support (measured as any use whatsoever). However, no studies have critically evaluated the use of cardiovascular infusions in the first 24-hour postoperative period or the influence of anesthetic technique on weight gain when control- ling for steroid administration. Fast-track protocols (Table i) were implemented at this institution at the request of the cardiac surgeons. To study the influence of fast-tracking, a retrospective cohort study was undertaken to evaluate the hypothesis that conventional and fast-track cardiac surgical patients are not statistically signifi- cantly different with respect to cardiovascular drug infusions, weight gain, myocardial infarction, death, pulmonary complica- tions, length of intubation, rate of reintubation, length of ICU stay, and length of hospital stay. METHODS After obtaining institutional review board approval, a research instrument was completed retrospectively for each patient by a cardio- vascular ICU (CVICU) registered nurse who had undergone training for the study. This review incorporated information on each patient's anesthetic technique, as well as preoperative risk factors (Table 2) and preoperative medications (digitalis, angiotensin-converting enzyme inhibitors, antiarrhythmics, diuretics, aspirin, beta-blockers, antiplatelet drugs, calcium channel blockers, steroids, nitrates, anticoagulants, thrombolytics, and inotropes). Surgical procedural factors that could also independently influence patient outcomes were evaluated (Table 3). Patient outcomes were recorded for each variable under investigation, as defined in Table 4. Data sources included laboratory, radiographic, electrocardiographic, and cardiac catheterization studies, as well as physician notes, anesthetic, extracorporeal, and nursing records, and the Thoracic Surgeons' National Cardiac Surgery Database data collection form. The database was maintained using SPSS for Windows, version 424 Journal of Cardiothoracic and Vascular Anesthesia, Vo113, No 4 (August),1999: pp 424-430