Treatment of patients undergoing cardiac surgery in a Fast-Track-Protocol in specialized anesthetic care unit compared to treatment in a Fast-Track-Protocol on ICU

ISRCTN ISRCTN71768341
DOI https://doi.org/10.1186/ISRCTN71768341
Secondary identifying numbers N/A
Submission date
24/02/2014
Registration date
11/03/2014
Last edited
21/08/2014
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Surgery
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data

Plain English summary of protocol

Background and study aims
Anesthesia for cardiac surgery has traditionally been provided with high-dose opioids and long-acting muscle relaxants, in the belief this technique was associated with optimal haemodynamic stability (blood circulation). However, these drugs could stay much more longer in the body after the cardiac surgery . This leads to prolonged postoperative mechanical ventilation (assisted breathing) and increased length of stay in the intensive care unit (ICU). This was considered to be an acceptable compromise; however, rising costs and the need for faster ICU turnover in the face of increased demand and reduced resources led the focus to reducing the length of ICU stay after cardiac surgery. Reducing postoperative mechanical ventilation was identified as a key factor for reducing ICU length of stay. Since the mid-1990s, intensified postoperative rehabilitation has established itself as the best approach to patient recovery and it was called fast-track treatment. Fast-track treatment has become a popular and accepted standard because it allows for early end of mechanical ventilation (extubation) within six hours and consequently reduced length of stay in the ICU and hospital. A significant reduction in time to extubation without compromising patient safety has been shown. However, earlier extubation has not always led to a reduction in ICU length of stay. Studies have shown that the implementation of a dedicated fast-track protocol allows not only for earlier extubation but also for earlier transfer from the ICU or the postoperative anesthesia care unit (PACU) to a step down unit. Utilised in combination, this approach has been associated with both significant cost savings and also increased ICU bed capacity. Most fast-track treatment protocols for cardiac surgery patients to date, however, have been implemented within the conventional ICU setting and not in a PACU. This study aims to compare the effectiveness of the fast-track protocol executed in a PACU and in an ICU.

Who can participate?
Patients scheduled to undergo cardiac surgery.

What does the study involve?
Patients were randomly allocated to one of two groups, either the PACU group or the ICU group, and were treated with the same fast-track protocol. The fast-track protocol included early extubation and mobilisation of the patients. All patients were transferred to PACU/ICU mechanically ventilated. Postoperative analgesia (pain killers) consisted of opioids, plus regular paracetamol to achieve tolerable postoperative pain for patients. The primary goal was to get the patients in a condition were they were conscious and followed commands, had stable spontaneous ventilation, were hemodynamically stable, not bleeding, and with no abnormalities of heart rhythm (ECG). Criteria for discharge to the intermediate care unit (IMC) were that patients must be awake, cooperative, and had stable function of the cardiovascular system and the lung.

What are the possible benefits and risks of participating?
For patients treated in the PACU earlier recovery of all functions is expected compared to patients treated in ICU. No additional risks are expected for fast-track treatment.

Where is the study run from?
University Hospital Leipzig, Germany.

When is the study starting and how long is it expected to run for ?
The study ran from May 2008 until September 2009.

Who is funding the study?
University of Leipzig, Germany

Who is the main contact?
Dr Stefan Probst, University Hospital Leipzig, Department of Anesthesia
stefan.probst@web.de

Contact information

Mr Christof Cech
Scientific

Struempellstrasse 39
Leipzig
02489
Germany

Study information

Study designProspective randomized trial
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Hospital
Study typeTreatment
Participant information sheet Not available in web format, please use the contact details below to request a patient information sheet
Scientific titleA specialized post anesthetic care unit improves Fast-Track-Management in cardiac surgery: a prospective randomized trial
Study objectivesTreatment of patients with the same fast track protocol in a postoperative anesthetic care unit compared to ICU will reduce postoperative mechanical ventilation as well as postoperative anesthetic care unit stay compared to ICU.
Ethics approval(s)Ethics Commitee, Medical Faculty, University of Leipzig, Haertelstrasse 16-18, 04107 Leipzig, 03/04/2008, ref: 097-2008
Health condition(s) or problem(s) studiedAnesthetic fast track protocol in cardiac surgery
InterventionAn anesthetic fast track protocol for cardiac surgery patients will be compared for patients passing trough an postoperative anesthetic care unit and a ICU.

Treatment for both groups contains:
1. Oral premedication with dipotassium-clorazepate (20-40 mg) the evening before and midazolam (3.75-7.5 mg) on the day of surgery
2. Induction of anaesthesia with fentanyl (0.2 mg), propofol (1.5-2 mg/kg) and a single dose of rocuronium (0.6 mg/kg)
3. Analgesia was maintained throughout the case with a continuous infusion of remifentanil (0.2 mcg/kg/min), and for hypnosis during the pre- and post-cardiopulmonary bypass (CBP) period sevoflurane (0.8 – 1.1 MAC) was administered whereas during CPB a continuous propofol infusion (3 mg/kg/h) was used.
4. Postoperative analgesia consisted of an bolus of piritramide (0.1 mg/kg) on discontinuation of the remifentanil infusion, followed by bolus doses as required in 2-4 mg aliquots, plus regular paracetamol (1 g every 6 hours) to achieve a pain score between 2 to 4 on an analogue pain scale from 0 to 10.
5. Patients were extubated when they were conscious and obeyed commands, had stable spontaneous ventilation with pressure support 10-12 cmH2O, PEEP 5 cmH2O, FiO2 ≤ 0.4, were hemodynamically stable, not bleeding (≤100 ml/hr), and with no significant electrocardiographic abnormalities

The total duration of treatment was expected u to 24 hours. Patients were followed up until discharge from hospital.
Intervention typeProcedure/Surgery
Primary outcome measureExtubation time and Postanesthesia Care Unit (PACU)/Intensive Care Unit (ICU) length of stay (LOS). Primary endpoints will be measured from the time point were the patient reaches PACU/ICU.
Secondary outcome measures1. Hospital LOS
2. Overall length of intensive care treatment (Total ICT LOS)
3. In-house mortality
4. Low cardiac output
5. New onset cardiac arrhythmia, respiratory failure requiring prolonged ventilation or re-intubation and incidences of surgical re-exploration and renal failure.

Secondary endpoint hospital length of stay is measured from the time were patient were admitted to the hospital. Total ICT LOS is measured from admitting the patient to PACU/ICU All other secondary outcomes are measured at baseline.
Overall study start date01/05/2008
Completion date30/09/2009

Eligibility

Participant type(s)Patient
Age groupAdult
SexBoth
Target number of participants200
Key inclusion criteriaEvery patient scheduled to undergo CABG, valve surgery, or combined CABG and valve surgery
Key exclusion criteria1. Patients who were in cardiogenic shock
2. Were dialysis dependent
3. Had an additive EuroSCORE of more than 10
Date of first enrolment01/05/2008
Date of final enrolment30/09/2009

Locations

Countries of recruitment

  • Germany

Study participating centre

Struempellstrasse 39
Leipzig
02489
Germany

Sponsor information

University Hospital Leipzig (Germany)
Hospital/treatment centre

c/o Jörg Ender
Struempellstrasse 39
Leipzig
04289
Germany

ROR logo "ROR" https://ror.org/028hv5492

Funders

Funder type

University/education

Heart Center Leipzig - University of Leipzig (Germany)

No information available

Results and Publications

Intention to publish date
Individual participant data (IPD) Intention to shareNo
IPD sharing plan summaryNot provided at time of registration
Publication and dissemination planNot provided at time of registration
IPD sharing plan

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Results article results 15/08/2014 Yes No