CORONARY-ARTERY BYPASS-GRAFTING ON PUMP - ROLE OF 3-DAY DISCHARGE

Background. A new emphasis has been directed toward ''off-pump'' coron ary artery bypass grafting to avoid the morbidity of cardiopulmonary b ypass and further reduce the postoperative hospital length of stay. Wi th the intent of achieving a hospital discharge for ''on-pump'' corona ry artery bypass grafting procedures comparable with the same procedur es ''off pump,'' we applied a rapid-recovery protocol with particular attention paid to patients eligible for discharge on the third postope rative day. Methods. The cases of 104 consecutive patients who underwe nt isolated coronary artery bypass grafting using cardiopulmonary bypa ss were retrospectively reviewed. A rapid-recovery protocol emphasizin g reduced cardiopulmonary bypass time, an anesthesia protocol for earl y extubation, perioperative administration of corticosteroids and thyr oid hormone, and aggressive diuresis was applied to all patients. The goal during the first 24 hours postoperatively was to achieve early ex tubation as well as a mild state of negative fluid balance and to ensu re absence of postoperative bleeding and a safe transfer from the inte nsive 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 wi thout assistance, had return of normal bowel function, and had no atri al fibrillation, a 3-day discharge home was planned. Results. The 30-d ay mortality rate for the entire group was 1.9%. The average postopera tive hospital length of stay for the entire series was 4.8 +/- 2.4 day s. Of the 102 survivors, 30 patients (29%) were discharged within 3 da ys postoperatively (group 1), and 72 patients (71%) were discharged af ter the third postoperative day (group 2). Patients in group 1 were yo unger and had fewer comorbid conditions. Compared with group 2, group 1 had fewer patients with diabetes (7% versus 28%; p < 0.05), congesti ve heart failure (7% versus 18%), symptomatic vascular disease (0% ver sus 11%), chronic obstructive pulmonary disease (0% versus 10%), ambul atory difficulties (0% versus 10%), and the requirement of an intraaor tic balloon pump preoperatively (13% versus 35%). Group 1 patients als o had almost no complications and a lower readmission rate (3.3% versu s 6.9%). Conclusions. With the application of a rapid-recovery protoco l to patients undergoing ''on-pump'' coronary artery bypass grafting, discharge home within 3 days postoperatively is attainable and safe fo r patients who have minimal comorbid conditions. (C) 1997 by The Socie ty of Thoracic Surgeons.