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Abstract 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 scarce resources. “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). |