Fast‐track cardiac care for adult cardiac surgical patients

Wai‐Tat Wong; Veronica KW Lai; Yee Eot Chee; Anna Lee

doi:10.1002/14651858.CD003587.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 2 Time‐directed extubation protocols, outcome: 2.4 Subgroup analysis.

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Analysis 1.1

Comparison 1 Dose of opioid‐based cardiac anaesthesia, Outcome 1 Mortality.

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Analysis 1.2

Comparison 1 Dose of opioid‐based cardiac anaesthesia, Outcome 2 Postoperative complications.

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Analysis 1.3

Comparison 1 Dose of opioid‐based cardiac anaesthesia, Outcome 3 Service outcomes.

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Analysis 2.1

Comparison 2 Time‐directed extubation protocol, Outcome 1 Mortality.

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Analysis 2.2

Comparison 2 Time‐directed extubation protocol, Outcome 2 Postoperative complications.

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Analysis 2.3

Comparison 2 Time‐directed extubation protocol, Outcome 3 Service outcomes.

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Analysis 2.4

Comparison 2 Time‐directed extubation protocol, Outcome 4 Subgroup analysis.

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Summary of findings for the main comparison. Low‐dose opioid‐based GA vs high‐dose opioid‐based GA

Low‐dose opioid‐based general anaesthesia compared with high‐dose opioid‐based general anaesthesia for adults undergoing cardiac surgery
Patient or population: adult cardiac surgical patients Setting: people undergoing various cardiac surgical procedures in hospitals in Europe, North America, Asia, Australasia and Middle East Intervention: low‐dose opioid‐based general anaesthesia Comparison: high‐dose opioid‐based general anaesthesia
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with high‐dose opioid‐based general anaesthesia	Risk with low‐dose opioid‐based general anaesthesia
Mortality ‐ Death at any time after surgery	Low		OR 0.53 (0.25 to 1.12)	1994 (8 RCTs)	⊕⊕⊝⊝ LOW^a,b	No death recorded in 3 trials
	10 per 1000	5 per 1000 (3 to 11)
	Moderate
	30 per 1000	16 per 1000 (8 to 33)
	High
	110 per 1000	61 per 1000 (30 to 122)
Postoperative myocardial infarction	Study population		RR 0.98 (0.48 to 1.99)	1683 (8 RCTs)	⊕⊕⊝⊝ LOW^a,b	No postoperative myocardial infarction recorded in 2 trials
	30 per 1000	30 per 1000 (15 to 60)
Postoperative stroke	Study population		RR 1.17 (0.36 to 3.78)	562 (5 RCTs)	⊕⊕⊝⊝ LOW^b,c	No stroke recorded in 1 trial
	18 per 1000	21 per 1000 (6 to 67)
Postoperative tracheal reintubation	Study population		RR 1.77 (0.38 to 8.27)	594 (5 RCTs)	⊕⊕⊝⊝ LOW^b,d	No reintubation recorded in 3 trials
	7 per 1000	12 per 1000 (3 to 55)
Time to extubation (hours)	Mean time to extubation (hours) was 5.2 to 35.1	Mean time to extubation (hours) in the intervention group was 7.4 lower (10.51 lower to 4.29 lower).	‐	2486 (14 RCTs)	⊕⊕⊝⊝ LOW^e,f
Length of intensive care unit stay (hours)	Mean length of intensive care unit stay (hours) was 2.6 to 112.8.	Mean length of intensive care unit stay (hours) in the intervention group was 3.7 lower (6.98 lower to 0.41 lower).	‐	1394 (12 RCTs)	⊕⊕⊝⊝ LOW^f,g
Length of hospital stay (days)	Mean length of hospital stay (days) was 5.1 to 27.0.	Mean length of hospital stay (days) in the intervention group was 0.3 lower (1.04 lower to 0.43 higher).	‐	913 (8 RCTs)	⊕⊕⊝⊝ LOW^f,h
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group using the EuroSCORE risk classification (Michel 2003) and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; OR: odds ratio.
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^aOf the 8 trials, 2 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^bOptimal information size not met (downgrade 1 point owing to imprecision). ^cOf the 5 trials, 1 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^dOf the 5 trials, 2 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^eOf the 14 trials, 4 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^fUnexplained reasons for high heterogeneity. ^gOf the 12 trials, 3 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^hOf the 8 trials, 3 had ≥ 1 high risk of bias domain (downgrade 1 point owing to study limitations).

Summary of findings for the main comparison. Low‐dose opioid‐based GA vs high‐dose opioid‐based GA

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Summary of findings 2. Time‐directed extubation protocol vs usual care

Time‐directed extubation protocol compared with usual care for adults undergoing cardiac surgery
Patient or population: adult cardiac surgical patients Setting: people undergoing various cardiac surgical procedures in hospitals in Europe, North America, Asia and Middle East Intervention: time‐directed extubation protocol Comparison: usual care
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with usual care	Risk with time‐directed extubation protocol
Mortality ‐ Death at any time after surgery	Low		OR 0.80 (0.45 to 1.45)	1802 (10 RCTs)	⊕⊕⊝⊝ LOW^a,b	No deaths recorded in 4 trials. Low to moderate heterogeneity (I² = 37%) may be explained by the inclusion of a trial (Reyes 1997) that had the highest rate of mortality of all trials considered. When excluded, the OR changed to 0.31 (95% CI 0.11 to 0.90, P = 0.03, I² = 0%).
	10 per 1000	8 per 1000 (5 to 14)
	Moderate
	30 per 1000	24 per 1000 (14 to 43)
	High
	110 per 1000	90 per 1000 (53 to 152)
Postoperative myocardial infarction	Study population		RR 0.59 (0.27 to 1.31)	1378 (8 RCTs)	⊕⊕⊝⊝ LOW^b,c	No postoperative myocardial infarction was recorded in 1 trial.
	61 per 1000	36 per 1000 (16 to 80)
Postoperative stroke	Study population		RR 0.85 (0.33 to 2.16)	1646 (11 RCTs)	⊕⊕⊝⊝ LOW^b,d	No stroke was recorded in 2 trials.
	12 per 1000	10 per 1000 (4 to 26)
Postoperative reintubation	Study population		RR 1.34 (0.74 to 2.41)	1261 (12 RCTs)	⊕⊕⊝⊝ LOW^b,e	No reintubation was recorded in 3 trials.
	28 per 1000	38 per 1000 (21 to 68)
Time to extubation (hours)	Mean time to extubation (hours) was 3.4 to 18.9.	Mean time to extubation (hours) in the intervention group was 6.25 lower (8.84 lower to 3.67 lower).	‐	2024 (16 RCTs)	⊕⊕⊝⊝ LOW^f,g	No variation in time to extubation in the early extubation group in 1 trial
Length of intensive care unit stay (hours)	Mean length of intensive care unit stay (hours) was 17.9 to 95.0.	Mean length of intensive care unit stay (hours) in the intervention group was 7.16 lower (10.45 lower to 3.88 lower).	‐	1888 (13 RCTs)	⊕⊕⊝⊝ LOW^f,h	No variation in length of ICU stay in early extubation group in 1 trial
Length of hospital stay (days)	Mean length of hospital stay (days) was 5.1 to 13.0.	Mean length of hospital stay (days) in the intervention group was 0.44 lower (1.04 lower to 0.16 higher).	‐	1334 (8 RCTs)	⊕⊕⊝⊝ LOW^f,i
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group using the EuroSCORE risk classification (Michel 2003) and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; OR: odds ratio.
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect but may be substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^aOf the 10 trials, 3 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^bOptimal information size not met (downgrade 1 point owing to imprecision). ^cOf the 8 trials, 3 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^dOf the 11 trials, 5 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^dOf the 12 trials, 5 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^fUnexplained reasons for high heterogeneity. ^gOf the 16 trials, 6 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ^hOf the 13 trials, 5 had 1 high risk of bias domain (downgrade 1 point owing to study limitations). ⁱOf the 8 trials, 2 had 1 high risk of bias domain (downgrade 1 point owing to study limitations).

Summary of findings 2. Time‐directed extubation protocol vs usual care

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Comparison 1. Dose of opioid‐based cardiac anaesthesia

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	8		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

1.1 Death in hospital after surgery	7	1896	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.58 [0.24, 1.39]
1.2 Death at 1 year after surgery	2	446	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.55 [0.17, 1.82]
1.3 Death at any time after surgery	8	1994	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.53 [0.25, 1.12]
2 Postoperative complications Show forest plot	10		Risk Ratio (IV, Random, 95% CI)	Subtotals only

2.1 Postoperative myocardial infarction	8	1683	Risk Ratio (IV, Random, 95% CI)	0.98 [0.48, 1.99]
2.2 Stroke	5	562	Risk Ratio (IV, Random, 95% CI)	1.17 [0.36, 3.78]
2.3 Acute renal failure	4	492	Risk Ratio (IV, Random, 95% CI)	1.19 [0.33, 4.33]
2.4 Major bleeding	4	469	Risk Ratio (IV, Random, 95% CI)	0.48 [0.16, 1.44]
2.5 Reintubation	5	594	Risk Ratio (IV, Random, 95% CI)	1.77 [0.38, 8.27]
3 Service outcomes Show forest plot	14		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Time to extubation (hours)	14	2486	Mean Difference (IV, Random, 95% CI)	‐7.40 [‐10.51, ‐4.29]
3.2 Length of intensive care unit stay (hours)	12	1394	Mean Difference (IV, Random, 95% CI)	‐3.70 [‐6.98, ‐0.41]
3.3 Length of hospital stay (days)	8	913	Mean Difference (IV, Random, 95% CI)	‐0.30 [‐1.04, 0.43]

Comparison 1. Dose of opioid‐based cardiac anaesthesia

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Comparison 2. Time‐directed extubation protocol

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	10		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

1.1 Death in the intensive care unit	2	370	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.87 [0.19, 3.88]
1.2 Death in hospital after surgery	5	582	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.23 [0.05, 1.04]
1.3 Death at 1 month after surgery	4	1122	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.13 [0.59, 2.19]
1.4 Death at any time after surgery	10	1802	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.80 [0.45, 1.45]
2 Postoperative complications Show forest plot	15		Risk Ratio (IV, Random, 95% CI)	Subtotals only

2.1 Postoperative myocardial infarction	8	1378	Risk Ratio (IV, Random, 95% CI)	0.59 [0.27, 1.31]
2.2 Stroke	11	1646	Risk Ratio (IV, Random, 95% CI)	0.85 [0.33, 2.16]
2.3 Acute renal failure	9	1541	Risk Ratio (IV, Random, 95% CI)	1.11 [0.42, 2.91]
2.4 Major bleeding	10	1244	Risk Ratio (IV, Random, 95% CI)	0.92 [0.53, 1.61]
2.5 Major sepsis	3	477	Risk Ratio (IV, Random, 95% CI)	2.40 [0.31, 18.25]
2.6 Wound infection	2	868	Risk Ratio (IV, Random, 95% CI)	0.67 [0.25, 1.83]
2.7 Reintubation	12	1261	Risk Ratio (IV, Random, 95% CI)	1.34 [0.74, 2.41]
3 Service outcomes Show forest plot	16		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Time to extubation (hours)	16	2024	Mean Difference (IV, Random, 95% CI)	‐6.25 [‐8.84, ‐3.67]
3.2 Length of intensive care unit stay (hours)	13	1888	Mean Difference (IV, Random, 95% CI)	‐7.16 [‐10.45, ‐3.88]
3.3 Length of hospital stay (days)	8	1334	Mean Difference (IV, Random, 95% CI)	‐0.44 [‐1.04, 0.16]
4 Subgroup analysis Show forest plot	11		Risk Ratio (IV, Random, 95% CI)	Subtotals only

4.1 Reintubation after extubation in ICU	8	934	Risk Ratio (IV, Random, 95% CI)	1.99 [0.93, 4.23]
4.2 Reintubation after extubation outside ICU	3	127	Risk Ratio (IV, Random, 95% CI)	3.82 [0.44, 33.24]

Comparison 2. Time‐directed extubation protocol

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