The purpose of this study was to identify the independent risk factors for fast-track failure (FTF) in cardiac surgery patients.
A study by Kiessling and colleagues within Germany found a mean LOS of 10.3 ± 2.5 days in patients with a successful fast track and a mean LOS of 16.5 ± 16.3 days when fast-track failure occurred [17].
Published figures for fast-track failure rates range from 11%to49%9% depending on the patient population [ 17, 18, 24].
We carefully selected fast-track patients at the end of surgery following the criteria identified as risk factors for fast-track failure [ 1, 17, 18].
As our primary end point was postoperative ventilation time, we defined fast-track failure as postoperative ventilation of more than six hours.
Fast-track failure risk models after cardiac surgery have been developed 8 and externally validated 9 to facilitate the planning of perioperative care pathways, but factors associated with failure of enhanced recovery protocol after HBP surgery are unknown.
Another explanation for the low fast-track failure rate of 5% for the PACU group is the fact that the final decision for inclusion of the patient to fast-track treatment was made at the end of the surgery.
We primarily excluded patients with a defined risk for fast-track failure during the premedication visit (patients who were scheduled for emergency surgery, were in cardiogenic shock, were dialysis dependent, or had an additive EuroSCORE of more than 10) [ 1, 17, 25].
This underlines the hypothesis that not only careful preselection of potential fast-track patients during the premedication visit is important, but also that re-evaluation of patient suitability at the end of the operation can lead to a reduction of fast-track failure.
The relatively high fast-track failure rate for the ICU group (67% time to extubation >6 hours and 29% PACU/ICU LOS >24 hours) may be attributable to several factors: first, the much better physician-to-patient ratio in the PACU (1 3 in the PACU vs. 1 12 in the ICU) allows the physician to effectively implement and manage an early goal-directed therapy.
Delaying the decision about patient suitability for fast-track treatment until the end of surgery may also contribute to reducing the incidence of fast-track failures.
