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Table 1 Technique for fast-track cardiac anesthesia compared to standard care protocol

From: Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative

Standard care

Fast-track protocol

Preoperative medication

Preoperative medication

Oral benzodiazepine (temazepam 10 mg or diazepam 10 mg)

Intramuscular morphine 10–20 mg, 1 h before surgery

Nil premedication

Insertion of vascular access (conscious sedation)

Insertion of vascular access (conscious sedation)

At discretion of treating anesthesiologist: midazolam (3–5 mg IV) or diazepine, morphine (5–10 mg) or oxycodome (5–10 mg)

Midazolam (1–3 mg IV), fentanyl (50–100 ug)

Induction of anesthesia

Induction of anesthesia

Opioid at discretion of treating anesthesiologist

Fentanyl (3–5 ug/kg IV) or alfentanil (30–50 ug/kg IV)

Neuromuscular blocking agent selected at discretion of treating anesthesiologist

Rocuronium (1 mg/kg) or vecuronium 0.1 mg/kg for neuromuscular blockade

Maintenance of anesthesia/analgesia

Maintenance of anesthesia/analgesia

Intraoperative opioids, benzodiazepines, volatile agents, and total intravenous anesthesia is at the discretion of the treating anesthesiologist

Remifentanil: (0.1–0.3 ug/kg/min IV) or TCI (3–6 ng/ml) or alfentanil (0.2–0.5 ug/kg/min IV)

Desflurane or sevoflurane: maintaining 1 MAC

Anesthesia during CPB

Anesthesia during CPB

Morphine (10 mg IV bolus) start of CPB

Propofol 1–2 mg/kg/h maintaining a Bispectral Index of 40–60

Volatile anesthesia maintaining a Bispectral Index of 40–60

Continue intraoperative analgesia infusions

Post CPB

Post CPB

No reversal agent administered

Sugammadex for reversal (200 mg IV)

Morphine/oxycodone (5–10 mg IV) at discretion of the treating anesthesiologist

Additional analgesia with small aliquots fentanyl (50–100 ug) or morphine/oxycodone (5–10 mg IV)

Nasogastric or oral gastric tube left in situ to decompress stomach and suction any gastric contents

Single pass oral gastric tube to decompress stomach and suction any gastric contents, then removed

No paracetamol or ketamine

Stop remifentanil or alfentanil during insertion of sternal wires

Start ketamine 0.1 mg/kg/h

Paracetamol 1 g IV

Extubation

Extubation

Transfer from operating room to to ICU

Endotracheal tube in-situ

Mechanically ventilated and sedated

At discretion of attending intensive care clinician:

• Weaning from mechanical ventilation

• Spontaneous breathing trial

• Enodotracheal tube extubation

• Transfer to cardiac care unit ward bed

At completion of surgery stop anesthesia agents and initiate spontaneous breathing trial:

• Continuous reduction in continuous positive airway pressure to minimal ventilator settings i.e. 5 cmH20 pressure support and 2–5 mmH2O PEEP (ensure arterial saturation > 92%, PaCO2 < 55 mmHg, FiO2 < 0.4, PaO2/FiO2 > 200 and respiratory rate < 20 b/min;

• Adequate mentation

• Pain controlled

• Head lift off pillow, raise arms in air for 10 s

• Stable hemodynamics

• Normothermia

Extubate on operating table or transfer patient on propofol infusion (20–40 mg/h) to ICU for continuation of spontaneous breathing trial and extubation in ICU

Postoperative analgesia

Postoperative analgesia

Opioid patient controlled analgesia (PCA) at discretion of treating intensivist. Type of opiod and opioid regime not standardized

Patient controlled analgesia (PCA) fentanyl (10 ug/bolus, 5 min boluses, 5 min lockout, no background infusion)

Paracetamol (1 g IVI) at discretion of treating intensivist

Paracetamol (1 g IVI) every 6 h for 48 h

Adjunctive analgesia per ICU

Tramadol (50–100 mg IV) or ketamine (0.05–0.1 mg/kg/h IV) if refractory analgesia

No acute pain service review

Acute pain service review twice daily

Postoperative agitation/delirium

Postoperative agitation/delirium

Sedation/antipsychotics at discretion of treating intensivist

Dexmedetomidine (0.2 ug/kg/h)

  1. This table highlights the important differences between patients receiving the fast-track protocol compared to standard protocol. Notable differences occur throughout the care process, with more specific guidelines being introduced for postoperative care in the FTCA group including extubation, analgesia and management of delirium