Perioperative Predictors of Ultra-Fast-Track Failure and Prolonged Hospital Length of Stay in a Preliminary Protocol of Enhanced Recovery after off-Pump Coronary Artery Bypass Grafting

Background: The use of Ultra-fast-track (UFT) management in cardiac surgery may shorten hospital length of stay (Hosp-LOS) when is part of a protocol of enhance recovery after surgery (ERAS).

Methods: We retrospectively analyzed the data of the patients undergoing elective off-pump coronary artery bypass grafting (OPCAB) using UFT under a pilot program of ERAS at a Venezuelan nonprofit cardiac center from 2010 to 2014. The primary goal was to describe the short-term outcome of a consecutive case-series managed with desflurane-remifentanil-intercostals nerve block for OPCAB by Left-Anterolateral Thoracotomy and followed up by multidisciplinary enhance recovery pathway. The secondary goals were to identify perioperative predictors for UTF-failure and Hosp-LOS> 4 days.

Results: 1,943 bypasses were performed on 673patients. 61.5 ± 9.5 years old, EuroSCORE was 5.2± 4.1 . 97.8% was extubated in Operating Room (UFT-success) and 2.2% extubated in the intensive care unit (UFT-failure). The reintubation rate was 0.5%. Patients had an Intensive Care Unit length of stay (ICU-LOS) of 29 ± 4.2 hours; 636 patients (94.5%) had ICU-LOS≤24 hrs, 2.1% readmitted to ICU. The Hosp-LOS after discharge from ICU was 50.5 ± 9.9 hours, 633 (94.1%) had Hosp-LOS ≤4days. Univariate analysis revealed as independent risk factors for UFT-failure: age, female sex, EuroSCORE, Severity of Angina Pectoris, EF<30%, Redo, COPD, PRBC transfusion, use of elective IABP and duration of surgery (t-Qx). However, multivariate logistic regression analysis and backward elimination method found as strong risk factors for UFT-failure: transfusion of ≥2 PRCB Adjusted Odds Ratio (AOR=6.02) (95%CI) (p<0.05), t-Qx 3-4 hrs, (AOR=77.3)(95%CI) (p<0.001) and t-Qx > 4 hrs, (AOR= 157.5) (95%CI) (p<0.001). Univariate analysis revealed as independent risk factors for Hosp-LOS >4 days: Age>80 yo ,female sex, NYHA>III, EuroSCORE, severity of Angina pectoris, EF<30%, Redo, renal failure, IABP, PRCB transfusion, UFT-failure, t-Qx and ICU-LOS (p<0.001). Multivariate logistic regression analysis and backward elimination method found as strong risk factors for Prolonged Hosp-LOS (>4days): Redo (AOR=7.68) (95%CI), t-Qx >3 hrs (AOR>74) (95%CI) (p<0.001) and ICU-LOS>24hrs (AOR=29.3) (95%CI) (p<0.001).

Conclusion: As most patients were extubated in the Op.Room, had short ICU-LOS (<24 hrs) and short Hospital-LOS (≤4days). UTF appears to have clinical benefits in this setting. In general, age >80 y.o, female sex, severity of EuroSCORE and ≥2 PRBCs transfusion were risk factor for UTF-failure and prolonged Hosp-LOS. However, the stronger predictive factors for UTF-failure and Hosp-LOS >4days were transfusion of ≥2 PRCB, Redo, duration of surgery>3 hrs and ICU-LOS>24hrs. Prospective studies would better elucidate the risk factors for longer Hospital-LOS and attendant morbidities.

Keywords: Ultra-fast track, off-pump coronary artery bypass graft, left anterolateral thoracotomy, beating heart, early extubation, enhanced recovery after surgery (ERAS).