Engelman R M
Baystate Medical Center, Springfield, Massachusetts 01107, USA.
Ann Thorac Surg. 1996 Feb;61(2 Suppl):S26-9; discussion S33-4. doi: 10.1016/0003-4975(95)01081-5.
The present era of medicine is concerned to a large measure with cost containment and the advent of managed care. For these reasons the concept of reducing hospital stays with a concomitant reduction in hospital cost is very attractive. The role of fast track is to ensure that we are not placing the patient at any additional risk and in fact are improving recovery and patient well-being.
Fast track is based on a specific protocol that is followed for each patient. Intensive preoperative education of patient and family familarize them with early discharge. Anesthetic technique is modified to effect early (4 to 8 hours) postoperative extubation. Steroids are administered perioperatively to improve myocardial function and reduce the release of inflammatory mediators. Digoxin is given prophylactically as are the bowel-mediating drugs metoclopramide, docusate, and ranitidine. The fast-track protocol is associated with aggressive ambulation of the patients and cardiac rehabilitation, so that the patient is out of bed the first day after operation, walking in the hall the second day, and up a flight of stairs the third day.
A shift to fast track in 1992 permitted comparison between 282 non-fast-track patients and 280 fast-track patients undergoing coronary artery bypass grafting. The results showed no adverse consequences of fast track. Forty-eight percent of fast-track patients were discharged at 3 to 5 days compared with 26% of non-fast-track patients. No significant differences were found between the two groups with respect to infection (1%), operative mortality (approximately 4%), and 30-day hospital readmission (7% non-fast-track and 8% fast-track). A postdischarge questionnaire addressed issues of patient and family satisfaction. The early discharge patient had a 77% comfort level, whereas their family members felt satisfied with a 3- to 5-day hospital stay in only 54% of cases. These data suggest the need for better communication, education, and additional postdischarge support systems.
A fast-track protocol allows faster recovery and earlier discharge from both the intensive care unit and the hospital without apparent increased risk. Complicated patients can also be fast tracked, and the desire to do so may actually expedite recovery.
当今医学时代在很大程度上关注成本控制和管理式医疗的出现。出于这些原因，减少住院时间并同时降低医院成本的理念非常有吸引力。快速康复的作用是确保我们不会给患者带来任何额外风险，实际上是在促进康复和提高患者的健康水平。
快速康复基于针对每位患者遵循的特定方案。对患者及其家属进行强化术前教育，使他们熟悉早期出院。调整麻醉技术以实现术后早期（4至8小时）拔管。围手术期给予类固醇以改善心肌功能并减少炎症介质的释放。预防性给予地高辛以及肠道调节药物甲氧氯普胺、多库酯和雷尼替丁。快速康复方案与患者积极活动及心脏康复相关，这样患者术后第一天就可下床，第二天在病房走廊行走，第三天可上一层楼梯。
1992年转向快速康复，使得282例接受冠状动脉搭桥术的非快速康复患者与280例快速康复患者得以进行比较。结果显示快速康复没有不良后果。48%的快速康复患者在3至5天出院，而非快速康复患者的这一比例为26%。两组在感染（1%）、手术死亡率（约4%）和30天内再次入院率（非快速康复组7%，快速康复组8%）方面没有显著差异。一份出院后问卷涉及患者及其家属的满意度问题。早期出院患者的舒适度为77%，而其家属仅在54%的情况下对3至5天的住院时间感到满意。这些数据表明需要更好的沟通、教育和额外的出院后支持系统。
快速康复方案可使患者在重症监护病房和医院更快康复并更早出院，且无明显风险增加。复杂患者也可采用快速康复，这样做的意愿实际上可能加快康复。
