Stock Sina, Berger Veith Sarah, Holst Theresa, Erfani Sahab, Pochert Julia, Dumps Christian, Girdauskas Evaldas
Department of Cardiac and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany.
Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany.
Front Cardiovasc Med. 2024 Aug 12;11:1412869. doi: 10.3389/fcvm.2024.1412869. eCollection 2024.
Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring.
358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU).
Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery ( = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement ( = 79) and aortic surgery ( = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU.
If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.
术后加速康复（ERAS）的重点是在大手术后实现更快的功能恢复。术后ERAS的一个重要方面是降低发病率和减少因长期重症监护导致的活动受限。利用当前的临床数据，我们的目的是分析微创心脏手术（MICS）后六小时的监测期是否足以在未来的快速康复路径中识别主要的术后并发症。此外，我们试图研究是否有可能降低术后监测的级别。
2021年1月至2023年3月期间，我们机构有358例患者接受了MICS手术，并被认为适合采用ERAS方案。其中，297例患者在手术台上成功拔管，病情稳定地转入IMC或ICU，因此作为研究队列。关注的结果包括主要不良心脏事件（MACE；死亡、需要血管重建的心肌梗死、中风）的发生率和发生时间、需要再次手术探查的出血情况以及与快速康复相关的并发症（再次插管和再次入住ICU）。
患者的中位年龄为63岁（四分位间距55 - 70岁），65%为男性。189例（64%）患者接受了前外侧小切口开胸手术，主要用于二尖瓣和/或三尖瓣手术（n = 177）。108例（36%）患者进行了部分上胸骨切开术，主要用于主动脉瓣修复/置换（n = 79）和主动脉手术（n = 17）。90%的患者术后6小时内血压正常，无需使用血管升压药，82%的患者在术后第1天（POD）转入普通病房。发生了2例（0.7%）MACE事件，以及4例（1.3%）需要再次手术探查的术后出血事件。在这些并发症中，只有1例在转入病房前发生，所有其他事件均发生在POD 1或之后。有1例再次插管和2例再次入住ICU的情况。
根据我们单中心的经验，如果MICS患者能够在手术台上成功拔管且血流动力学稳定，主要的术后并发症很少见，且主要发生在转入病房后。因此，对于术中过程无并发症且经过精心挑选的MICS患者，在可能不在ICU的情况下监测6小时，然后转入病房似乎是一个可行的理论概念，对患者安全没有负面影响。
