“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