Coronary artery bypass grafting "on pump": role of three-day discharge.
BACKGROUND
A new emphasis has been directed toward "off-pump" coronary artery bypass grafting to avoid the morbidity of cardiopulmonary bypass and further reduce the postoperative hospital length of stay. With the intent of achieving a hospital discharge for "on-pump" coronary artery bypass grafting procedures comparable with the same procedures "off pump," we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postoperative day.


METHODS
The cases of 104 consecutive patients who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass were retrospectively reviewed. A rapid-recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthesia protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early extubation as well as a mild state of negative fluid balance and to ensure absence of postoperative bleeding and a safe transfer from the intensive care unit to a monitored floor. On the second postoperative day, chest drains were discontinued, and aggressive ambulation therapy was instituted. If at 72 hours postoperatively the patient was walking without assistance, had return of normal bowel function, and had no atrial fibrillation, a 3-day discharge home was planned.


RESULTS
The 30-day mortality rate for the entire group was 1.9%. The average postoperative hospital length of stay for the entire series was 4.8 +/- 2.4 days. Of the 102 survivors, 30 patients (29%) were discharged within 3 days postoperatively (group 1), and 72 patients (71%) were discharged after the third postoperative day (group 2). Patients in group 1 were younger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congestive heart failure (7% versus 18%), symptomatic vascular disease (0% versus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambulatory difficulties (0% versus 10%), and the requirement of an intraaortic balloon pump preoperatively (13% versus 35%). Group 1 patients also had almost no complications and a lower readmission rate (3.3% versus 6.9%).


CONCLUSIONS
With the application of a rapid-recovery protocol to patients undergoing "on-pump" coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe for patients who have minimal comorbid conditions.
Ott
R A
RA
Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange 92668, USA.
Gutfinger
D E
DE
Miller
M P
MP
Selvan
A
A
Codini
M A
MA
Alimadadian
H
H
Tanner
T M
TM
D000368:Aged; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass / Q000401:mortality; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011183:Postoperative Complications; D012189:Retrospective Studies