Do Enhanced Recovery Programmes Improve Outcomes In Adult Cardiac Surgery?
Katharina Schulte1, Rizwan Attia2.
1St Hedwig Hospital, Charité University Berlin, Berlin, Germany, 2St Bartholomew's Hospital, London, London, United Kingdom.
Background: Enhanced recovery programmes (ERP) are a major innovation in the care of general surgical patients, reducing perioperative complications, length of stay (LOS) and reducing costs. It is unclear how these relate to the post cardiac surgery population.
Methods: We analysed all databases for studies which evaluated ERP after cardiac surgery from 1999-2016. A total of 5 studies were identified; 3 studies (2 prospective, 1 retrospective) comparing a fast-track recovery vs. a control group; 2 studies (1 prospective, 1 retrospective) assessing the reasons for failure of fast track recovery programmes.
Results: A total of 368 patients were included. Retrospective study (n=74) showed a significant reduction of the total LOS in the ERP-group (4.05+/-1.43vs.5.4+/-1.17), P=0.003). Prospective study (n=272) had a reduction in the intensive care unit (ICU) LOS (14.38hours (range2.83-202.00), SD31.27vs.26.79+/-11.58hours (range 14.42-50.00), P<0.001) in the ERP-group. There was an additional reduction in the duration of intubation (3.36+/-2.54hours (range0.25-18.57) vs.5.11+/-2.87hours (range1.17-13.17),P<0.001) and a cost effectiveness compared to conventional recovery (£4182±2284 vs. £4553±1355, mean difference £371(£166-£1324), P<0.001).
There was a significant reduction in the number of postoperative complications (one or more complications: 50.9% vs. 19.2%, P<0.01) and an improvement in postoperative pain scores (P<0.01) in the ERP cohorts. A total of 346 complications occurred in 3,317 patients (1704patients, 11.6% in-hospital complications, 5.6% complications post discharge; and 1,613 patients with 3.53% readmission rate for complications) were observed.
In case of readmission there was an association with a longer second ICU stay (105+/-180hrs vs. 19.2+/-2.4hrs of initial ICU stay). There was a significant mortality with readmissions (6 of 53,11.3%) in the ERP-group. Independent risk factors for ERP failure were age (in-hospital OR 1.406,P<0.01; post discharge OR1.386,P<0.01), female sex (in-hospital OR1.509,P<0.01), prolonged surgery (in-hospital OR 1.382,P<0.01, post discharge OR1.672,P<0.01).
Conclusion: Small retrospective and prospective studies demonstrate fast track recovery after cardiac surgery as an important management strategy in carefully pre-selected patient groups decreasing the intensive care LOS, total duration of intubation, potentially the LOS and is a cost effective strategy compared to conventional recovery. There is a lack of randomised trail data assessing which components of the fast tracking system contribute most to the outcomes.
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