Standard care | Fast-track protocol |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Sedation/antipsychotics at discretion of treating intensivist | Dexmedetomidine (0.2 ug/kg/h) |