A new scoring system to predict fast-track failure in cardiac surgery.

I ncreasing medical expenses in healthcare systems throughout the world mandate a closer look at individual practices to reduce costs. During the last years, a rising number of cardiac surgical procedures has been reported by the American Heart Association ( 600,000 in 2003), mostly due to older patients who are considered “high risk” secondary to substantial comorbidities. The postsurgical intensive care unit (ICU) is an important cost component ( US$3,000–4,000/patient day) after (cardiac) surgeries (1). All intensive care units across specialties account for 25–30% of hospital costs, representing 1–2% of the gross national product (between US$40 and US$80 billion per year) despite the fact that ICU beds represent only 5–10% of hospital beds (2). Earlier discharge to less costly and less workintense postsurgical care wards decreases the overall expenditure on postoperative care and hospitalization. The concept of fast-track cardiac surgery and recovery has been tested and established to minimize expenses without lowering the quality of patient care. Components of fast-track management include fast-acting anesthetic agents, normothermia, early extubation, and “offpump” cardiac surgeries. Various studies have shown the safety of different fasttrack approaches (3–6). To optimize the selection of cardiac patients for different treatment strategies and to assess the operative risk in cardiac surgery (7, 8), various scoring systems have been developed (e.g., Parsonet, European System for Cardiac Operative Risk Evaluation [EuroSCORE], Cleveland Clinic Score, French Score, Pons Score, Ontario Province Risk Score). Risk stratification is a useful tool to analyze trends in operative and postoperative therapy and changes in patient populations. However, the relevance and accuracy of these scores and their predictive values have been questioned (9–12). For fasttrack cardiac surgical management yielding a shortened ICU stay and a reduction of readmission rates (13), an “ideal” scoring system to define suitable patient populations over a wide range of surgical complexities has not been fully established. In this issue of Critical Care Medicine, Dr. Constantinides and colleagues (14) identified predictive factors for fast-track failure (FTF) in a prospective singlecenter clinical trial in the United Kingdom. A predictive FTF scoring system, using unifactorial analysis and a multifactorial logistic regression model, was developed. Some 1,084 patients undergoing open cardiac surgery were included, and data were collected during a 2-yr period. All patients were preoperatively evaluated using a standardized protocol. Analyzed data included demographics, comorbidities, previous surgeries, preoperative general health status, indications for surgery, time to extubation, operative mode and procedure, readmission to the ICU, and predicted mortality based on the EuroSCORE (15). Patients requiring dialysis, patients with cardiothoracic trauma, and patients who were considered fast-track candidates but were directly admitted to the ICU (due to bed shortage) were excluded. Postoperatively, fast-track candidates were admitted to the fast-track unit. In contrast to the multidisciplinary ICU, the fast-track unit had a “lower tech” environment, and postoperative patient management was mainly performed by nurses under supervision of cardiothoracic surgeons. In comparison to previous studies, which mostly excluded higher risk procedures in their analysis (1, 16), this trial included more complex cardiac operations such as coronary bypass grafting combined with single valve replacement (mitral or aortic), double valve replacements, and major thoracic aortic surgeries. However, similar to other studies, the majority of evaluated operations were coronary artery bypass procedures (17, 16). The authors reported that 169 patients (15.6%) failed fast-track management, and FTF score was based on the following predictors: a) a recent acute coronary syndrome with poor left ventricular function; b) re-do operations; c) preexisting extracardiac arteriopathy; d) preoperative intra-aortic balloon pump; e) increased serum creatinine; f) operative urgency; and g) complex surgeries. Based on a mathematical model, the correlation between probability of FTF and the score was clearly supported; for example a score 9 (with 10.9 total points possible) predicted FTF in 99.8% of cases. We think that their authors’ FTF score system may be a promising tool for perioperative risk stratification and postoperative disposition of more complex cardiac surgical patients and should lead us to think about how to translate this into U.S. practice. It seems to be a highly predictive score but has to be confirmed in multiple-center trials with a larger number of patients. The EuroSCORE trials included and tested 19,000 patients. Since fast-track protocols differ between hospitals and centers within and between countries, attempting to find an international scoring system with common denominators would make a lot of sense. Vanessa Moll, MD Haitham Mutlak, MD Wolfgang Steudel, MD Department of Anesthesiology Division of Cardiothoracic Anesthesia University of Colorado at Denver Health Sciences Center Denver, CO