A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial

Abstract

Introduction: Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end-points in adult patients after elective cardiac surgery.

Methods: In a prospective, single blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new onset cardiac arrhythmia, low cardiac output syndrome, need for cardio-pulmonary resuscitation, stroke, acute renal failure, and death.

Results: Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P < 0.001). Median length of stay in PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P < 0.001). Of the adverse events examined, only the incidence of new onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups.

Conclusions: Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step down unit, without compromising patient safety.

Trial registration: ISRCTN71768341. Registered 11 March 2014.

Figure 1

Study flowchart.

Figure 2

Primary extubation time, P <0.001, outliers >1500 min are masked out (n = 3 in ICU group).

Figure 3

Length of stay in post-anaesthetic care unit vs. intensive care unit, P <0.001, outliers >50 hours are masked out (n = 7 in ICU group). ICU, intensive care unit.

Figure 4

Total ICT LOS = total intensive care treatment, length of stay in PACU/ICU + IMC including readmissions, P  = 0.08, outliers >200 hours are masked out (n = 2 in PACU group, n = 6 in ICU group). ICU, intensive care unit; IMC, intermediate care unit; LOS, length of stay; PACU, post-anaesthetic care unit.