Effect of Sedation Strategy on the Hospital Length of Stay and ICU Length of Stay after On-Pump Cardiac Surgeries
Over the past decades, many approaches have been changed in intensive care and in anesthesiology. Most of these changes were included in the guidelines now well known as fast-track protocols (protocols for enhanced recovery after surgery). Cardiac anesthesiology was not an exception. Preoperative, intraoperative and postoperative management of the patient are the main components of these protocols, which are aimed at reducing the length of stay (LOS) of patients in the hospital and intensive care units (ICU).
The aim. To detect the relationship between the sedation strategy and the duration of the hospital LOS and the ICU LOS.
Materials and methods. This was a randomized, controlled, parallel study. We analyzed 194 patients over 18 years of age who underwent cardiac surgical treatment using artificial blood circulation. Statistical data processing was carried out on the basis of GraphPad Prism 9.0 software.
Results. According to our research, the average hospital LOS was 7.779 ± 2.844 days in the propofol group (n = 95), 7.188 ± 1.601 days in the dexmedetomidine group (n = 16). In the group where patients were sedated with a combination of drugs (n = 83), the average length of hospitalization was 5.904 ± 1.535 days. The average ICU LOS was 2.463 ± 1.090 days in the propofol group and 2.375 ± 1.360 days in the dexmedetomidine group. In the group where patients were sedated with a combination of drugs (n = 83), the average ICU LOS was 2.361 ± 0.8776 days. The hospital LOS of patients who were sedated with a combination of drugs was lower (p < 0.0001). When comparing the ICU LOS, no difference was found in all three sedation groups (p = 0.3903).
According to the analysis conducted in the propofol group, the ICU LOS was shorter in patients who did not receive vasoactive therapy (p = 0.0299). In the dexmedetomidine sedation group, no difference was found between the ICU LOS in patients with or without vasoactive support (p = 0.5289). In the group of patients who underwent sedation with a combination of drugs, the ICU LOS was shorter in the group of patients who underwent correction with vasoactive drugs (p < 0.0001).
Conclusion. Sedation with a drug combination (dexmedetomidine and propofol) may reduce hospital LOS (p < 0.0001). There was no influence of any sedation strategy on the ICU LOS (p = 0.3903). Early initiation of vasoactive support with sedative drug combination (dexmedetomidine and propofol) shortens the ICU LOS (p < 0.0001).
- Winings NA, Daley BJ, Bollig RW, Roberts RF Jr, Radtke J, Heidel RE, et al. Dexmedetomidine versus propofol for prolonged sedation in critically ill trauma and surgical patients. Surgeon. 2021;19(3):129-134. https://doi.org/10.1016/j.surge.2020.04.003
- Maj G, Regesta T, Campanella A, Cavozza C, Parodi G, Audo A. Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review. J Cardiothorac Vasc Anesth. 2022;36(3):766-775. https://doi.org/10.1053/j.jvca.2021.02.035
- Kiefer J, Feinman J, Gutsche J, Augoustides JG. 35 - Fast-Track Cardiac Anesthesia: A Vital Core of Perioperative Cardiac Surgery Programs. In: Fleisher LA, editor. Evidence-Based Practice of Anesthesiology. 4th ed. Philadelphia:Elsevier;2022. p. 300-308. https://doi.org/10.1016/B978-0-323-77846-6.00035-5
- Muller Moran HR, Maguire D, Maguire D, Kowalski S, Jacobsohn E, Mackenzie S, et al. Association of earlier extubation and postoperative delirium after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2020;159(1):182-190.e7. https://doi.org/10.1016/j.jtcvs.2019.03.047
- Yu PJ, Lin D, Catalano M, Cassiere H, Kohn N, Hartman A. Predictors of Increased Length of Hospital Stay in Patients with Severe Cardiomyopathy Undergoing Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth. 2019;33(10):2703-2708. https://doi.org/10.1053/j.jvca.2019.03.017
- Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, et al. The anesthesiologist’s perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg. 2023;36(2):363-379. https://doi.org/10.1053/j.semvascsurg.2023.04.017
- Almashrafi A, Elmontsri M, Aylin P. Systematic review of factors influencing length of stay in ICU after adult cardiac surgery. BMC Health Serv Res. 2016;16:318. https://doi.org/10.1186/s12913-016-1591-3
- Takata ET, Eschert J, Mather J, McLaughlin T, Hammond J, Hashim SW, et al. Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching. J Cardiothorac Vasc Anesth. 2023;37(1):31-41. https://doi.org/10.1053/j.jvca.2022.10.009
- Mahesh B, Choong CK, Goldsmith K, Gerrard C, Nashef SA, Vuylsteke A. Prolonged Stay in Intensive Care Unit Is a Powerful Predictor of Adverse Outcomes After Cardiac Operations. Ann Thorac Surg. 2012;94(1):109-116. https://doi.org/10.1016/j.athoracsur.2012.02.010
- Almashrafi A, Alsabti H, Mukaddirov M, Balan B, Aylin P. Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study. BMJ Open. 2016;6(6):e010764. https://doi.org/10.1136/bmjopen-2015-010764
- Padilha KG, Sousa RM, Kimura M, Miyadahira AM, da Cruz DA, Vattimo Mde F, et al. Nursing workload in intensive care units: A study using the Therapeutic Intervention Scoring System-28 (TISS-28). Intensive Crit Care Nurs. 2007;23(3):162-169. https://doi.org/10.1016/j.iccn.2006.07.004
- Jansson M, Ohtonen P, Syrjälä H, Ala-Kokko T. The proportion of understaffing and increased nursing workload are associated with multiple organ failure: a cross-sectional study. J Adv Nurs. 2020;76(8):2113-2124. https://doi.org/10.1111/jan.14410
- Eltheni R, Giakoumidakis K, Brokalaki H, Galanis P, Nenekidis I, Fildissis G. Predictors of Prolonged Stay in the Intensive Care Unit following Cardiac Surgery. ISRN Nurs. 2012;2012:691561. https://doi.org/10.5402/2012/691561
- Passaroni AC, Silva MA, Yoshida WB. Cardiopulmonary bypass: development of John Gibbon’s heart-lung machine. Rev Bras Cir Cardiovasc. 2015;30(2):235-245. https://doi.org/10.5935/1678-9741.20150021
- Tunç M, Şahutoğlu C, Karaca N, Kocabaş S, Aşkar FZ. Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery in Adults. Turk J Anaesthesiol Reanim. 2018;46(4):283-291. https://doi.org/10.5152/TJAR.2018.92244
- Stoppe C, Goetzenich A, Whitman G, Ohkuma R, Brown T, Hatzakorzian R, et al. Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery. Crit Care. 2017;21(1):131. https://doi.org/10.1186/s13054-017-1690-5
- Chermesh I, Hajos J, Mashiach T, Bozhko M, Shani L, Nir RR, et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol. 2014;21(4):475-483. https://doi.org/10.1177/2047487312452969
- Abowali HA, Paganini M, Enten G, Elbadawi A, Camporesi EM. Critical Review and Meta-Analysis of Postoperative Sedation after Adult Cardiac Surgery: Dexmedetomidine Versus Propofol. J Cardiothorac Vasc Anesth. 2021;35(4):1134-1142. https://doi.org/10.1053/j.jvca.2020.10.022
- Diab MS, Bilkhu R, Soppa G, Edsell M, Fletcher N, Heiberg J, et al. The influence of prolonged intensive care stay on quality of life, recovery, and clinical outcomes following cardiac surgery: A prospective cohort study. J Thorac Cardiovasc Surg. 2018;156(5):1906-1915.e3. https://doi.org/10.1016/j.jtcvs.2018.05.076
- Azarfarin R, Ashouri N, Totonchi Z, Bakhshandeh H, Yaghoubi A. Factors influencing prolonged icu stay after open heart surgery. Res Cardiovasc Med. 2014;3(4):e20159. https://doi.org/10.5812/cardiovascmed.20159
- Peterson ED, Coombs LP, Ferguson TB, Shroyer AL, DeLong ER, Grover FL, et al. Hospital variability in length of stay after coronary artery bypass surgery: results from the Society of Thoracic Surgeon’s National Cardiac Database. Ann Thorac Surg. 2002;74(2):464-473. https://doi.org/10.1016/s0003-4975(02)03694-9
- Sultana I, Erraguntla M, Kum H-C, Delen D, Lawley M. The Interrelationships between the length of stay, readmission, and post-acute care referral in cardiac surgery patients. Healthcare Analytics. 2022;2:100062. https://doi.org/10.1016/j.health.2022.100062
- Liu H, Ji F, Peng K, Applegate RL 2nd, Fleming N. Sedation After Cardiac Surgery: Is One Drug Better Than Another? Anesth Analg. 2017;124(4):1061-1070. https://doi.org/10.1213/ANE.0000000000001588
- Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al.; American College of Critical Care Medicine. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med. 2013;41(1):263-306. https://doi.org/10.1097/CCM.0b013e3182783b72
- McGovern C, Cowan R, Appleton R, Miles B. Pain, agitation and delirium in the intensive care unit. Anaesthesia & Intensive Care Medicine. 2021;22(12):799-806. https://doi.org/10.1016/j.mpaic.2021.10.013
- Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell- Bright S, Levitt J, et al. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med. 2006;34(5):1326-1332. https://doi.org/10.1097/01.CCM.0000215513.63207.7F
- Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al.; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs Midazolam for Sedation of Critically Ill patients: A Randomized Trial. JAMA. 2009;301(5):489-499. https://doi.org/10.1001/jama.2009.56
- Qu JZ, Mueller A, McKay TB, Westover MB, Shelton KT, Shaefi S, et al.; MINDDS Study Team. Nighttime dexmedetomidine for delirium prevention in non- mechanically ventilated patients after cardiac surgery (MINDDS): a single-centre, parallel-arm, randomised, placebo-controlled superiority trial. EClinicalMedicine. 2023 Feb;56:101796. https://doi.org/10.1016/j.eclinm.2022.101796
- Imai K, Morita T, Yokomichi N, Kawaguchi T, Kohara H, Yamaguchi T, et al. Efficacy of Proportional Sedation and Deep Sedation Defined by Sedation Protocols: A Multicenter, Prospective, Observational Comparative Study. J Pain Symptom Manage. 2021;62(6):1165-1174. https://doi.org/10.1016/j.jpainsymman.2021.06.005
- Pandharipande P, Cotton BA, Shintani A, Thompson J, Pun BT, Morris JA Jr, et al. Prevalence and Risk Factors for Development of Delirium in Surgical and Trauma Intensive Care Unit Patients. J Trauma. 2008;65(1):34-41. https://doi.org/10.1097/TA.0b013e31814b2c4d
- Arroliga AC, Thompson BT, Ancukiewicz M, Gonzales JP, Guntupalli KK, Park PK, et al.; Acute Respiratory Distress Syndrome Network. Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med. 2008;36(4):1083-1088. https://doi.org/10.1097/CCM.0B013E3181653895
- Fong JJ, Kanji S, Dasta JF, Garpestad E, Devlin JW. Propofol Associated with a Shorter Duration of Mechanical Ventilation than Scheduled Intermittent Lorazepam: A Database Analysis Using Project IMPACT. Ann Pharmacother. 2007;41(12):1986-1991. https://doi.org/10.1345/aph.1K296
- Djaiani G, Silverton N, Fedorko L, Carroll J, Styra R, Rao V, Katznelson R. Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology. 2016;124(2):362-368. https://doi.org/10.1097/ALN.0000000000000951
- Torbic H, Papadopoulos S, Manjourides J, Devlin JW. Impact of a Protocol Advocating Dexmedetomidine Over Propofol Sedation After Robotic-Assisted Direct Coronary Artery Bypass Surgery on Duration of Mechanical Ventilation and Patient Safety. Ann Pharmacother. 2013;47(4):441-446. https://doi.org/10.1345/aph.1S156
- Chima AM, Mahmoud MA, Narayanasamy S. What Is the Role of Dexmedetomidine in Modern Anesthesia and Critical Care? Adv Anesth. 2022;40(1):111-130. https://doi.org/10.1016/j.aan.2022.06.003
- Xia ZQ, Chen SQ, Yao X, Xie CB, Wen SH, Liu KX. Clinical benefits of dexmedetomidine versus propofol in adult intensive care unit patients: a meta-analysis of randomized clinical trials. J Surg Res. 2013;185(2):833-843. https://doi.org/10.1016/j.jss.2013.06.062
- Klompas M, Li L, Szumita P, Kleinman K, Murphy MV; CDC Prevention Epicenters Program. Associations Between Different Sedatives And Ventilator-Associated Events, Length of Stay, and Mortality in Patients Who Were Mechanically Ventilated. Chest. 2016;149(6):1373-1379. https://doi.org/10.1378/chest.15-1389
- Thoma BN, Li J, McDaniel CM, Wordell CJ, Cavarocchi N, Pizzi LT. Clinical and Economic Impact of Substituting Dexmedetomidine for Propofol due to a US Drug Shortage: Examination of Coronary Artery Bypass Graft Patients at an Urban Medical Centre. Pharmacoeconomics. 2014;32(2):149-157. https://doi.org/10.1007/s40273-013-0116-8
- Antel R, Yang S, Cameron M. Dexmedetomidine Versus Propofol for Sedation After Adult Cardiac Surgery: A Trial Sequential Analysis. J Cardiothorac Vasc Anesth. 2022;36(6):1810. https://doi.org/10.1053/j.jvca.2022.01.037
- Chen WC, Lin MH, Chen CL, Chen YC, Chen CY, Lin YC, et al. Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2021;10(5):1032. https://doi.org/10.3390/jcm10051032
- Hart SA, Tanel RE, Kipps AK, Hoerst AK, Graupe MA, Cassidy SC, et al. Intensive Care Unit and Acute Care Unit Length of Stay After Congenital Heart Surgery. Ann Thorac Surg. 2020;110(4):1396-1403. https://doi.org/10.1016/j.athoracsur.2020.01.033