Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up.

OBJECTIVES: An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. DESIGN: A retrospective cohort study. SETTING: A single academic center. PARTICIPANTS: Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. INTERVENTION: The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. MEASUREMENTS AND MAIN RESULTS: Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve = 0.676; 95% confidence interval, 0.611-0.741). CONCLUSION: Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.

Outcome of transplantation performed outside the regular working hours: A systematic review and meta-analysis of the literature.

Transplant procedures are frequently performed outside the regular working hours (after hours). In general surgery, several studies observed worse outcomes for operations performed after hours. The predetermined hypothesis was that patients undergoing transplantation during after hours might suffer from an excess in post-operative mortality and morbidity when compared to patients undergoing transplantations during the regular working hours. A systematic review of the PubMed database identified 11,993 records, of which eleven cohort studies including a total of 287,741 patients investigated the association between the starting time of transplant surgery and postoperative mortality (primary outcome) and/or morbidity (secondary outcome). Eight studies evaluated kidney transplants (in 165,277 patients), two studies analyzed liver transplants (in 95,346 patients), and one study investigated transplantations of thoracic organs (in 27,118 patients). Results were conflicting with two studies (in liver and lung transplantation) showing an increased mortality for transplantations performed after hours, and five studies showing no effects on mortality. A meta-analysis on estimates from four studies yielded a hazard ratio of 1.01 (95% CI, 0.98 to 1.04) for mortality comparing transplantations performed during versus outside the regular working hours. The evidence was also inconclusive for a variety of morbidity outcomes with studies demonstrating either a deterioration of outcome, no effect or an improved outcome for after hours procedures. On the basis of the available evidence, it appears impossible to give an unequivocal recommendation regarding starting times in transplant surgery.