Rapid recovery protocol applied to 5,658 consecutive "on-pump" coronary bypass patients

Background. Increasing hospital costs, restricted resources and new surgical strategies have stimulated effectiveness of all routines in cardiac surgery. Over a 10-year period, 5,658 consecutive patients undergoing coronary artery bypass grafting followed a protocol aiming at short postoperative intubation times and rapid physical rehabilitation. Methods. The patients were prepared for rapid recovery, emphasizing (1) preoperative education and respiratory training, (2) low-dose fentanyl anesthesia, (3) limited ischemic times and pump times, (4) mild hypothermia and rewarming to a rectal temperature of 36 degreesC, (5) restricted use of extended monitoring, (6) autologous blood salvage to avoid allogeneic blood transfusions, and (7) active physical training from postoperative day 1. All in-hospital data relevant to these steps were prospectively stored in a database. Results. The median extubation time after arrival in the intensive care unit was 1.5 hours (0 to 320 houri). More than 99% of the patients were extubated within 5 hours. Sixty-two patients (1.1%) were reintubated and ventilated far a median of 24 hours (1 to 430 hours), mostly due to resternotomy for bleeding or cardiopulmonary decompensation. In total, 5,594 patients (98.9%) were able to sit in a chair the first postoperative day. Within the fourth postoperative day, 82.5% were able to move freely in the hospital area and were in fact physically fit for hospital discharge. Allogeneic blood products were given to 3.9% of the patients. Twenty-three patients (0.41%) died in-hospital. Conclusions. With the application of a protocol for rapid physical recovery in patients undergoing "on-pump" coronary artery bypass grafting, extubation within 1 to 2 hours was safe and feasible in most patients. After 5 hours, 99.3% of the patients were extubated, with a reintubation rate of 1.1%. More than 80% of the patients were fully physically mobile within 4 days after the operation. (Ann Thorac Surg 2000;70:2008-12) (C) 2000 by The Society of Thoracic Surgeons.