Is fast-track cardiac anesthesia now the global standard of care?

Paul S. Myles, MB, BS, MPH, MD, FFARCSI, FANZCA† In this issue of Anesthesia & Analgesia Svircevic and colleagues from Utrecht, The Netherlands report on a retrospective cohort study examining the safety of fast-track cardiac anesthesia in 7998 patients undergoing cardiac surgery. In addition to adding data supporting the safety of this widely used technique, this article provides an opportunity to reflect on the overall status of this widely used approach in respect to anesthetizing patients undergoing cardiac surgery. Cardiac anesthesia has changed over the past 20 yr or so. In the 1960s, during the early days of coronary artery surgery, patients typically presented for surgery as an option of last resort. They were often in terminal cardiac failure after recurrent and sometimes protracted sequelae of their underlying ischemic heart disease. In circumstances such as these, induction of anesthesia with thiopental and maintenance with halothane was highly hazardous. It was, therefore, hailed as a breakthrough when high-dose opioid anesthesia was shown to be relatively cardio-stable. The payback for this stability was obligatory postoperative mechanical ventilation as a result of the prolonged respiratory depression which followed the high doses of morphine and, later, fentanyl and sufentanil. This situation was reinforced because the prolonged ventilation offered time to stabilize the patient’s hemodynamic, temperature, and blood gas variables and, importantly, to facilitate return to the operating room for postoperative bleeding. Some argued that prolonging intense analgesia with opioids in the intensive care unit (ICU) had further beneficial effects by decreasing postoperative ischemic episodes. In the 1990s, when growth in cardiac surgery outstripped ICU resources, economic rationalists began to scrutinize the costs of medical practice, ICU stay after cardiac surgery became an obvious target. Anesthesiologists were expected to cut the costs of postoperative care without jeopardizing patient safety. Responding to this challenge, a number of prospective randomized clinical trials were undertaken to demonstrate that low-dose opioids could be safely used for cardiac anesthesia. Low-dose opioid regimens enabled earlier tracheal extubation, and so provided an opportunity for less ICU resource utilization. Low-dose opioid anesthesia was given the label “fast-track;” a term borrowed from corporate jargon, and one that carries connotations of excitement and rapid advancement. One particularly influential study was done by Cheng et al. in Toronto. This randomized trial in 100 patients showed that their fast-track program significantly reduced ICU costs by 53% and surgical costs by 25% (both P 0.05) when compared with late tracheal extubation. The total hospital cost savings were 13% per patient and there were less elective case cancellations (both P 0.002). Others investigated opioidsparing central neuraxial blockade techniques. Executing randomized clinical trials is both labor-intensive and costly. Consequently, most studies examining the safety of fast-track cardiac anesthesia were limited to patient sample sizes of 150. In 2003, Myles et al. reported a systematic review of clinical trials comparing fast-track with traditional cardiac anesthesia. Their meta-analysis included 1800 patients enrolled in 10 trials, and confirmed a significant reduction in time to tracheal extubation, as well as a significant reduction in the duration of From the *Department of Anesthesia, St. Vincent’s Hospital, Melbourne, Australia; and †Department of Anesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia. Accepted for publication October 8, 2008. Address correspondence and reprint requests to Brendan S. Silbert, MB, BS, FANZCA, Department of Anesthesia, St. Vincent’s Hospital, Melbourne, Australia. Address e-mail to brendan.silbert@svhm.org. au. Copyright © 2009 International Anesthesia Research Society