SHA24/064005

“Fast track” Congenital Cardiac Surgery Osman Al-Radi, MSc, RFCSC King Abdulaziz University King Faisal Specialist Hospital & RC – Jeddah osman.al.radi@gmail.com Presentation and minor editing by: Abdullah A. Alghamdi, MD, MSc, FRCSC King Abdulaziz Cardiac Center, National Guard Health Affairs

Why “Fast track” ●

Safe

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Effective

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Cost cutting

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Improved return to normal lifestyle

What slows patients care down ? ●

Not ready for OR

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Inefficient (or worse) operation

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Bleeding

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Excessive anaesthesia and narcotics

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Unnecessary long intubation

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Narcotics and sedatives as pain management

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Excessive drainage

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Slow mobilization and entral feeding

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Anticoagulation

Components of FTP ●

Patient and family education and orientation

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Right diagnosis, right operation, right timing

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Blood conservation

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Minimal invasive operative methods

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Fast track anaesthetia, OR extubation

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Non-narcotic pain management

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Physiotherapy and ambulation

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Out patient drain and anticoagulation management

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Home-care service and Hot-line

Education and Orientation ●

Patient (>4-6 years)

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Parents

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One week preop visit

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Education

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Expected time and place

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Pain management

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Drains

Appropriate time off allowance to all care givers

4 Rights ●

Right DIAGNOSIS

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Right OPERATION –

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Case conference

Right TIMING of operation ●

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Ex. Fontan completion at 2-3 years vs. 5 to 8 years of age

Right POST-OP care

Blood conservation ●

Preoperative replenishment of iron stores

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Perfusion management and hemofiltration

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Meticulous hemostasis

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Criterion based transfusion –

Biventricular: Hg < 8-9

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Univentricular: Hg < 11-12

Minimal invasive ●

Partial sternotomy

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Small skin incision

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Small efficient (soft) drains Avoid excessive extrapericardial dissection Small dressings (psychological effect)

Anaesthesia and pain management ●

Plan before OR

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Criterion based OR extubation

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Minimal narcotics

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Local and neuraxial methods

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Post operative pain –

NSAID + Paracetamol – regular not PRN

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Avoid narcotics

Ambulation and entral feeding ●

Early ambulation

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Regular nurse driven physiotherapy

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Antiemetics

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Early oral fluids and nutrition

Home Health Care ●

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All patients should be included –

Minimum - telephone call next day

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Hot line for inquiries – charge nurse / oncall doctor

Management of prolonged chest drainage –

Specific drainage system

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Parent eduction and daily visit

Management of anticoagulation –

LMWH subcutanous once daily dose

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Home INR or daily visit to clinic

Supportive facilities ●

Transportation assistance

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Short stay apartments for out of city patients –

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Before and after surgery

Short term home care giver assistance

literature â&#x2014;?

Mostly focused on one aspect of fast track

â&#x2014;?

Early Extubation is a major part of fast tracking

literature

J. Cardiac Sur. 2010,25:586-595

Mortality

Re-intubation

ICU length of stay

Hospital stay

Total cost $

Respiratory morbidity

Study Underway

Study Underway

Summary ●

Early extubation –

Safe: no difference in mortality, reintubation

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Less respiratory morbidity

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Trends in less ICU and hospital stay

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Possibly reduced cost

Components of FTP ●

Patient and family education and orientation

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Right diagnosis, right operation, right timing

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Blood conservation and iron store replenishment

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Minimal invasive operative methods

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Fast track anaesthetia, OR extubation

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Non-narcotic pain management

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Physiotherapy and ambulation

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Out patient drain and anticoagulation management

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Home-care service and Hot-line

Conclusion ●

Fast track pediatric heart surgery –

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Safe and effective

Requires numerous low cost steps Involves multiple parties including patient and family

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Requires institutional support

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Potentially very coast effective or cost saving

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Allows increased productivity with limited resources