Probst et al, 2014: PACU for cardiac surgery

Probst S, Cech C, Haentschel D, Scholz M, Ender J. A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. Crit Care. 2014 Aug 15;18(4):468. [Epub ahead of print] PubMed PMID: 25123092. [Free Full Text]

• Does a specialised post anaesthetic care unit (PACU), compared to standard ICU care, lead to improvements in pre-defined fast-track endpoints such as extubation time and length of stay (LOS) in elective cardiac surgery patients?

TYPE OF STUDY

• Prospective single-blinded, single centre, randomised controlled trial

POPULATION

• n = 200 included in the trial
• n = 223 excluded, of which n=57 met the exclusion criteria and for n=171 there was no simultaneous PACU and ICU bed capacity at the end of surgery.

Inclusion criteria

• Patients for elective coronary artery bypass graft surgery, valve surgery or combined.

Exclusion criteria

• cardiogenic shock
• patients requiring renal replacement therapy
• EuroScore >10

INTERVENTIONS/ COMPARISONS

• Fast track treatment in ICU (n=100) vs fast tract treatment in a dedicated PACU (n=100)

OUTCOMES

• Fast-track treatment of cardiac surgery patients in a dedicated PACU compared to fast-track treatment in ICU significantly reduced time to extubation (90 vs. 478 min; p < 0.001) as well as time to transfer to a step down unit (LOS PACU 3.3 hours compared to 17.9 hours LOS ICU).

Criticisms

• selection of patients to enter PACU or ICU post-surgery is a critical design flaw when applied to the real world. To manage bed state effectively we need to be able to predict destination pre-operatively accurately, otherwise simultaneous free beds need to available as a backup (not easy to achieve, given that 171 patients needed to be excluded for this reason in this study).
• the patients are extremely well (mean EuroSCORE of 2 – you get 1 for being female!) and are not comparable to patients managed in our Cardiac ICU.
• This study was performed in a setting with a completely different staffing model to that typically used in Australasia (e.g. cardiac surgeons may determine ICU care and staffing ratios differ). The findings of this study cannot be applied to a closed intensivist-led ICU service with highly trained nurses with 1:1 staff:patient ratios.
• this study implies that a doctor (e.g. PACU anaesthetist) is needed for strict adherence to protocolised care, this is not the case in other ICU studies (e.g. weaning from ventilator), where ICU nurses are effective at ensuring protcolised care plans are followed.

Commentary

• the study does highlight the importance of appropriate adherence to protocolised-care plans to ensure patient progress.

Although this study showed decreased time to extubation and length of stay for elective cardiac surgery patients with the use of a PACU, it is not applicable to our setting.