Lee J H, Swain B, Andrey J, Murrell H K, Geha A S
Division of Cardiothoracic Surgery, University Hospitals of Cleveland, Ohio 44106, USA.
Ann Thorac Surg. 1999 Aug;68(2):437-41. doi: 10.1016/s0003-4975(99)00510-x.
To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon.
Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years).
The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14%+/-9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13%+/-7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6+/-2.8 days versus 7.2+/-3.7 days; 95% CI, 1.6+/-0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients.
Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.
为确定早期拔管和快速康复治疗方案在老年患者中是否可行，我们分析了1995年1月至1997年6月间连续进行单纯冠状动脉搭桥手术的487例患者，这些患者均为同一外科医生的手术病例。
所有患者均持续采用强调早期拔管方案、温和心脏停搏液和常温体外循环以缩短体外循环时间、早期活动和拔除胸管以及房颤规范治疗的管理方法。将至少70岁的老年患者（n = 176，平均年龄75岁）与年轻患者（n = 311，平均年龄58岁）进行比较。
医院死亡率为0.8%（487例患者中的4例），老年组与年轻组的手术死亡率无差异（0.6%对0.9%；p>0.05）。老年患者外周血管疾病、充血性心力衰竭、既往中风、肾衰竭和脑血管疾病的发生率较高（p<0.05）。71%的年轻患者实现了早期拔管，而老年组为57%（95%置信区间，14%±9%；p = .002）。老年患者术后房颤的发生率显著更高（27%对14%；95%CI，13%±7%；p<0.001），这是年轻患者住院时间较短的一个因素（5.6±2.8天对7.2±3.7天；95%CI，1.6±0.3天；p<0.001）。尽管如此，34%的老年患者在术后第５天之前出院。
尽管老年患者病情严重程度较高，但加速出院的关键路径在大多数老年患者中是安全可行的。
