Conference Lectures

Fast tracking in paediatric cardiac surgery(con)

Dr Jagadish Hegde
Consultant Anaesthesiologist
Sparsh Hospital Bangalore

Fast tracking in  cardiac surgery is a subject of debate now days. In adult cardiac surgery many people are practicing fast tracking regularly and claim many benefits. In paediatric cardiac surgery very few centres are practicing it and they also claim reasonable success.  But this method is highly controversial.
Whoever practices fast tracking protocols have the same concerns as whoever opposes it.
In the history of cardiac surgery fast tracking concept was there but for different reasons.  There was no  good ventilators to support patients ventilation for more time .ICU setup was less equipped. Trained manpower and fear of infection were there. All these factors lead to discharge patients from ICU  very early. They used to compromise on other aspects like bleeding issues; haemodynamic instabilities; pain management; early ventricular insults etc.
After that many things changed. Better ventilators  with lots of improvements made available for safe extended ventilation. People started using high opioid technique for better haemodynamics  because opioids  attenuate stress hormones better than other drugs. Because of use  of opioids  patients need to be ventilated for some more time.  People started doing more comlex procedures without worring about early extubation problems. Hospitals supported  these new concept because patient safety was more important and cost was secondary.
Now  because of lots of improvements  in medicines and techniques   and cost of patient management is really a matter of concern; many institutions and people have started of practicing fast tracking anaesthesia again.  Now many new drugs are available like improved volatile  anaesthetics;  new generation sedatives; and newer short acting but potent opioids. Many practitioners left high opioid techniques with conventional opioids for the fear of prolonged ventilation. Surgical  and cardiopulmonary bypass techniques  also have been improved . These things also added support to the fast tracking anaesthesia.
First off all the definition of fast tracking itself  is a controversy. Somebody says it is on table extubation ; somepeople say it is extubation with in few hours of the procedure and even somebody extended it upto 24 hours. So there is no common accepted definition. Opposers  and supporters have one thing in common ; patient’s safety.
The main complications in the early postperative period are respiratory depression; reintubation; bleeding’ haemodynamic instability.  Reintubation following haemodynamic instability has more serious  implications than conventional ventilation.
In adult cardiac surgery many practitioners are practicing fast track protocols and have got success.   Many studies have supported this. Main benefits are better lung function; early delining; early mobilization;  patients relatives satisfaction; early discharge from icu and hospital. So less morbidity;  and cost saving.
But in paediatric group surgery is mainly done for simple and complex cardiac conditions in very small babies to relatively larger children.  Fast tracking  has been tried in paediatric patients also. In simple cardiac procedures like ASD closure  studies  have been showed promising results. In children undergone fontan procedures  early extubation has shown benefits. But most of them are retrospective studies. We cannot come to the conclusions. Moreover in small children ;more complex procedures requiring more cardiopulmonary bypass time and crossclamp time results are showing not much advantage.reintubation rates are still high. Only prospective studies with large numbers can answer these questions.
With regard to cost studies have shown the reduced values. But they are retrospective studies. This is multidiciplinary approach. We need lots of technically efficient persons like surgeons; anaesthesiologists; technicians; nursing staff; and  special equipments and procedures. Not many studies have looked into it and compared
. So considering all these aspects  it is better to follow time tested methods than new experiments because patients life is more important than anything else.