A systematic review of the safety and effectiveness of fast-track cardiac anesthesia.

COST containment and efficient resource use have forced anesthesiologists to rethink their management strategies for cardiac surgery. In the late 1970s, when anesthetic practice predominantly involved inhalational anesthesia, it was possible to extubate cardiac surgical patients within a few hours after surgery. However, there was no economic pressure or incentive to practice cost-effective medicine at that time. An opioid-based anesthetic regimen gained popularity in the 1980s, when studies confirmed its ability to allow hemodynamic stability, even in patients with marginal cardiac reserve. This necessitated continuation of postoperative ventilatory support for 12–24 h in cardiac surgical patients. The growing need for intensive cardiovascular and ventilatory support during the immediate postoperative period in these patients required an expansion of intensive care unit (ICU) bed availability. Until recently, this need for postoperative ICU nursing care and length of stay had continued unchecked. The aims of “fast-tracking” cardiac surgical patients include early tracheal extubation and decreased length of ICU and hospital stay with subsequent cost reduction. Fast-track cardiac anesthesia (FTCA) techniques include the use of short-acting hypnotic drugs, reduced doses of opioids, or the use of ultrashort-acting opioids, and, in some cases, the use of antifibrinolytic drugs or drugs to prevent atrial fibrillation. There are purported benefits of early tracheal extubation and reduced duration of mechanical ventilation. Several randomized trials have found that early tracheal extubation can be safely achieved, and it may lead to reduced ICU stay and costs. Despite these findings, there are residual concerns regarding early tracheal extubation and FTCA. Studies to date have not included a sufficient number of patients to detect a clinically important effect on serious morbidity or mortality. The primary objective of this systematic review was to determine whether FTCA is as safe as traditional cardiac anesthesia (TCA) based on the administration of high doses of opioids. The hypothesis tested was that there is not an increased risk of mortality or major morbidity associated with FTCA compared with TCA.