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Minimally invasive cardiac surgery has been proposed to
reduce surgical trauma, decrease morbidity, lower the
procedural costs and increase patient satisfaction. Other
general advantages are that they provide access to the
relevant parts of the heart while reducing the need for
extensive dissection of surrounding tissue. Current data
seem to indicate that minimally invasive cardiac surgery is
not inferior to conventional surgery and also provides
several advantages when compared with conventional
approaches. (Gummert. et al, 2007).
Along with the development of new surgical techniques
and skills, the cardiac anesthesiologist is undoubtedly
facing new challenges. Minimally invasive surgery requires
a carefully orchestrated coordination of efforts between the
surgeon, perfusionist and anesthesiologist.
Minimally invasive cardiac surgical techniques have been
used to perform a variety of procedures in the fields of
coronary artery bypass grafting (CABG) and valve surgery.
(Nicolas. et al, 2008).
Interest in fast track protocols was rekindled because of a
growing pressure on the health systems worldwide due to
rapidly growing patient numbers, a steadily ageing patient
population, increasing comorbidities and increasingly
“Fast track” however is not a concept with a rigid, clear
definition, but rather a process for shortening any partial
aspect of the established procedure. The term “fast track”
includes the shortening of prolonged ventilatory support or
even the immediate postoperative extubation of heart
surgery patients, reducing ICU residence time or even direct transfer to an intermediate care unit, as well as reducing the
hospitalization time by already discharging the patient from
hospital on the first postoperative day.
(Kiessling. et al, 2013).
There are several potential benefits to early extubation. It
has been shown that earlier tracheal extubation hastens the
return of ciliary function and improves respiratory
dynamics and coughing. In fact, it has been proposed that
early extubation should decrease the incidence of
nosocomial pneumonia and the intrapulmonary shunt
fraction improved significantly among patients extubated
early. Moreover, mechanical ventilation itself can impair
venous return and decrease cardiac output, thus prolonging
ICU stay for the adjustment of these parameters.
As a fundamental component of fast track protocols, early
extubation has been shown to expedite the ICU discharge
as well as the overall hospital stay, thus resulting in a net
cost savings. Serious adverse effects were not observed in
any patient, suggesting that early extubation has both
clinical and economic benefits in cardiac surgery.
(Rashid, et al. 2008).
Major contributing factors for delayed extubation and
failure of fast track protocols were identified by this audit.
These factors need to be targeted accordingly by
modifications in intraoperative management.
Therefore, parameters should be used more strictly in fast
track patient selection and fast track termination.
(Haanschoten. et al, 2012).
An effective FTCA program requires the appropriate
selection of suitable patients, a low dose opioid anesthetic
technique, early tracheal extubation, a short stay in the
ICU and coordinated perioperative care. It is also
dependent on the avoidance of postoperative complications such as excessive bleeding, myocardial ischemia, low
cardiac output state, arrhythmias, sepsis and renal failure.
These complications will have a much greater adverse
effect on hospital length of stay and healthcare costs. A
number of clinical trials have identified interventions that
can reduce some of these complications. The adoption of
effective treatments into clinical practice should improve
the effectiveness of FTCA. (Thys, 2009).
Approach of the first FT protocols was focused on low
dose and/or short acting opioids. Now various methods of
drug administration are proposed to accomplish FT goals.
There is no standard protocol for anesthetics usage in FT
cardiac anesthesia and the best method of drug
administration is a controversial issue which merits further
investigation. (Najafi, 2008).
Neuraxial anesthesia, mainly thoracic epidural and high
spinal anesthesia, supplemented by general anesthesia is the
newest and, perhaps, the most controversial of all
anesthetic techniques used for cardiac surgery. This
combination of regional anesthesia supplemented by a light
plain of general anesthesia facilitates early extubation and
fast tracking. (Kowalewski. et al, 2011).
It is becoming increasingly clear that a multimodal
approach/combined analgesic regimen (utilizing a variety
of techniques) is likely the best way to approach
postoperative pain to maximize analgesia and minimize
side effects. When addressing postoperative analgesia in
cardiac surgical patients, choice of technique (or
techniques) is made only after a thorough analysis of the
risk/benefit ratio of each technique in the specific patient in
whom analgesia is desired. (Chaney. 2006). The timing of early extubation has varied among different
reports, and a precise definition of early extubation has not
been established. But the widely accepted definition is
extubating patients within eight hours after surgery.
(Camp. et al, 2010).
Immediate extubation of patients in the operating room (i.e.
ultra fast track cardiac anesthesia) is a further extension of
the fast-track technique. Immediate extubation can be seen
as the natural evolution, since the eight-hour interval
defining “fast track” recovery has a practical rather than
biological basis. However, its acceptance is hampered by
safety and economic concerns.
(Gangopadhyay. et al, 2010).
The optimal setting for postoperative cardiac care is a
matter of debate and several models have been proposed.
Specific intermediate or down-step care units could absorb
a part of the work usually done in a regular ICU. Surgeons
and anesthetists have to think outside the box, outside the
traditional operating room, ICU, down-step unit, ward
scheme to implement innovative peri-operative concepts
and adapting the postoperative settings to improve a
patient’s flow through the healthcare system.
(Roekaerts & Heijmans. 2012).