Long-term mechanical breathing, nocturnal sedation, & lengthy intensive care unit (ICU) monitoring have historically been linked to cardiac surgery. Relatively high dosages of long-acting opioids were often used in conventional anesthetic practice to reduce the body's reaction to substantial surgical stimulation & cardiopulmonary bypass. Long-term opioid use can postpone emergence, respiratory recovery, & extubation even while it is successful. This conventional method has been called into question by the introduction of fast-track cardiac anesthesia, which emphasizes time-directed extubation, early neurological recovery, short-acting hypnotics & analgesics, & reduced-dose opioids. Early randomized studies showed that, in carefully chosen individuals, early extubation after coronary artery bypass grafting (CABG) may be accomplished without increasing perioperative morbidity. [1-3] Fast-track cardiac care is increasingly seen as a crucial element of improved recuperation following heart surgery. It includes a number of coordinated interventions, including preoperative evaluation, anesthesia, surgery, ICU care, & postoperative rehabilitation. The ERAS Cardiac Society's recommendations place a strong emphasis on early extubation & mobilization, multimodal analgesia, proper anesthetic selection, & optimization of modifiable risk factors. [4] In appropriate individuals, current guidelines suggest extubation techniques within about 6 hours following surgery. [4,5]

Recent research has extended the idea from traditional fast-track extubation to ultra-fast-track anesthesia, where extubation can take place in the operating room or around an hour after surgery. Ultra-fast-track methods, however, are still only suitable for carefully chosen patients & necessitate significant institutional readiness. [6,7] Regional fascial plane blocks, dexmedetomidine, & adaptive support ventilation are among the interventions that may speed up extubation, according to a recent systematic review of randomized trials. However, the evidence for ultra-fast-track pathways is still less developed than that for extubation within three to six hours. [6]

Because extended mechanical ventilation following heart surgery is linked to longer hospital & intensive care unit stays, pulmonary morbidity, & resource consumption, early extubation is clinically significant. Therefore, the main advantages of fast-track approaches may come from synchronized recovery of respiratory, neurological, & cardiovascular function rather than only the removal of the endotracheal tube. [4,8]

The use of fast-track cardiac anesthesia may differ depending on institutional resources, patient characteristics, & surgical workload, despite strong worldwide evidence. Reducing ICU occupancy & making effective use of critical-care resources may be especially beneficial in emerging healthcare systems. Both the prevalence of cardiovascular illness & the demand for cardiac surgery services are rising in Central India. Nevertheless, there is still a dearth of documented institutional expertise in this area with fast-track anesthesia in adult heart surgery.

Aim

To assess the feasibility, safety & perioperative outcomes of fast-track anaesthesia in adult patients undergoing cardiac surgery at a tertiary care centre in Central India.

Objectives

1. To determine the proportion of adult cardiac surgical patients successfully extubated within 6 hours of ICU admission.
2. To evaluate the effect of successful fast-track extubation on duration of mechanical ventilation & ICU stay.
3. To assess hospital length of stay & postoperative complications.
4. To identify perioperative factors associated with delayed extubation.

This prospective observational study was conducted in Department of Cardiothoracic and Vascular Surgery and Department of Anesthesia, Superspeciality Hospital, M.G.M. Medical College, Indore, from August 2023 to December 2025. The study population comprised adult patients undergoing elective cardiac surgery under cardiopulmonary bypass. The study included 100 consecutive eligible patients. Institutional ethical approval & written informed consent were considered mandatory before enrolment. Patient selection Inclusion criteria: Patients were included if they: ● were aged 18 years or older; ● were scheduled for elective cardiac surgery; ● had an anticipated postoperative ICU admission; ● were haemodynamically stable before surgery; and ● provided informed consent. Exclusion criteria: Patients were excluded when they had: ● emergency cardiac surgery; ● preoperative mechanical ventilation; ● severe uncontrolled pulmonary disease; ● severe preoperative renal or hepatic dysfunction; ● haemodynamic instability requiring high-dose vasoactive support; ● major neurological impairment; ● complex aortic surgery; ● anticipated prolonged postoperative ventilation; or ● refusal to participate. Fast-track anaesthesia protocol Preoperative assessment included evaluation of cardiovascular & respiratory status, airway examination, renal function, haemoglobin, coagulation profile & echocardiographic findings. Standard monitoring included electrocardiography, pulse oximetry, invasive arterial pressure monitoring, central venous pressure monitoring, temperature, urine output & serial arterial blood gas analysis. Additional monitoring was used according to clinical requirement. Anaesthesia was induced using titrated short-acting agents with a reduced-dose opioid strategy. Maintenance anaesthesia consisted of a balanced technique using a short-acting intravenous and/or volatile hypnotic, supplemented by opioid analgesia according to surgical stimulation & haemodynamic response. Neuromuscular blockade was carefully monitored & appropriately reversed. Criteria for early extubation Extubation was considered when patients fulfilled all major criteria: ● adequate spontaneous respiratory effort; ● satisfactory oxygenation; ● normothermia; ● haemodynamic stability; ● acceptable arterial blood gas values; ● adequate reversal of neuromuscular blockade; ● appropriate level of consciousness; ● absence of significant ongoing bleeding; and ● low or stable vasoactive drug requirement. Statistical analysis Continuous variables were expressed as mean ± standard deviation & categorical variables as frequencies & percentages. Continuous variables were compared using the independent Student's t-test or Mann–Whitney U test where appropriate. Categorical variables were analyzed using the chi-square test or Fisher's exact test. A two-sided p-value <0.05 was considered statistically significant.

A total of 100 adult patients undergoing elective cardiac surgery were included. Seventy-eight patients (78%) achieved extubation within 6 hours of ICU admission & were categorized as the fast-track group, while 22 patients (22%) required delayed extubation.

The overall mean age was 56.7 ± 9.8 years. Males constituted 72% of the study population. CABG was the most common procedure, followed by valve surgery.

Table 1: Baseline demographic & clinical characteristics of study participants

Patients who achieved fast-track extubation were younger & had better preoperative left ventricular ejection fraction. Serum creatinine was also significantly lower in the successful fast-track group. Sex, BMI, hypertension & diabetes did not demonstrate statistically significant differences.

Table 2: Operative & anaesthetic characteristics

The fast-track group had significantly shorter cardiopulmonary bypass & aortic cross-clamp times. Intraoperative opioid exposure was significantly lower in the successful fast-track group. Total operative duration & blood loss were also lower.

These observations are consistent with previous literature identifying prolonged cardiopulmonary bypass & cross-clamp times as important contributors to delayed extubation. [8]

Table 3: Postoperative recovery & resource utilization

Successful fast-track patients demonstrated significantly earlier extubation, shorter mechanical ventilation, earlier oral intake & earlier ambulation. ICU & total hospital stays were also significantly shorter.

The mean time to extubation in the entire cohort was 4.8 ± 2.7 hours. Seventy-eight percent of patients met the predefined fast-track target.

Table 4: Postoperative complications & outcomes

Pulmonary complications were significantly less frequent among patients who successfully underwent fast-track extubation (10.3% vs. 27.3%; p=0.048). No statistically significant differences were observed for atrial fibrillation, acute kidney injury, bleeding requiring re-exploration, reintubation or mortality.

There were two reintubations in the fast-track group & two in the delayed-extubation group. The difference was not statistically significant.

This study assessed a standardized fast-track anesthesia pathway in 100 adult patients undergoing heart surgery & showed that 78% of patients could be extubated within 6 hours. Successful fast-track patients had much shorter stays in the hospital, intensive care unit, & on mechanical ventilation. Crucially, early extubation did not appear to be associated with higher mortality or serious postoperative sequelae. The realization that not all patients required lengthy postoperative artificial ventilation after straightforward heart surgery gave rise to the idea of fast-track cardiac anesthesia. Carefully chosen patients could be extubated earlier without experiencing higher perioperative morbidity, according to early randomized trials. According to Cheng et al., early extubation following CABG was safe & linked to shorter hospital & intensive care unit stays. [9] The safety of early extubation techniques utilizing reduced opioid dosages & anesthetic regimens suitable for quick recovery was later confirmed by similar randomized data. The current study's 78% fast-track success rate is clinically promising. Although definitions differ between research, recent reviews characterize early extubation as an increasingly recognized element of cardiac ERAS pathways. While ultra-fast-track methods may involve extubation in the operating room or during the first hour following surgery, fast-track extubation has traditionally been described as extubation within 6–8 hours following surgery. [10] The 6-hour criterion was specifically chosen for this investigation since it is both clinically feasible & compliant with ERAS guidelines. The 2019 ERAS cardiac surgery guideline emphasizes that early extubation can reduce ICU resource use without compromising safety in correctly selected patients, & it suggests tactics aiming at extubation within 6 hours of surgery. [11] Patients who experienced delayed extubation were considerably older. Because aging is linked to decreased pulmonary reserve, a higher prevalence of cardiac & non-cardiac comorbidities, & a delayed recovery from anesthesia, this conclusion is medically feasible. Delayed extubation was also linked to lower LVEF. Before they meet the requirements for extubation, patients with compromised ventricular function would need more vasoactive support & prolonged hemodynamic optimization.[12] Another important factor was renal impairment. The mean serum creatinine was greater in patients in the delayed group. In addition to indicating a higher overall burden of comorbidity, renal impairment may be a factor in fluid imbalance, metabolic abnormalities, & delayed medication clearance.[13] It seemed that operational considerations were very crucial. Patients who were unable to obtain fast-track extubation had considerably longer aortic cross-clamp & cardiopulmonary bypass procedures. This finding is consistent with earlier assessments that found extended bypass & cross-clamp length to be among the variables linked to delayed extubation more inflammatory response, more surgical complexity, & increased hemodynamic instability are frequently indicated by longer procedures. The fast-track group received a much lower intraoperative opioid dose. This is an essential part of fast-track cardiac anesthesia. Although traditional high-dose opioid methods offer significant hemodynamic stability, they may cause delayed awakening & protracted postoperative respiratory depression. Instead, modern fast-track methods combine short-acting hypnotics & multimodal analgesia with reduced opioid dosages. [14] In this study, the period of mechanical ventilation was significantly reduced. In contrast to patients who had delayed extubation, those who were successfully fast-tracked were ventilated for about 4 hours as opposed to roughly 15 hours. The length of stay in the intensive care unit was significantly reduced as a result of this difference. Previous research & comprehensive reviews have shown similar connections. [15] Early extubation, however, should not be seen as a goal that must be met regardless of the patient's health. According to a recent systematic analysis, patient selection is crucial & there is still no evidence to support prompt extubation in the operating room. According to recent research, ultra-fast-track tactics should only be used in situations with skilled personnel, suitable monitoring, & quick rescue ventilation.

Fast-track anaesthesia was feasible in a substantial proportion of appropriately selected adult patients undergoing cardiac surgery at a tertiary care centre in Central India. Seventy-eight percent of patients achieved extubation within 6 hours of ICU admission. Successful fast-track extubation was associated with significantly shorter mechanical ventilation, ICU stay & hospital stay, with no demonstrated increase in major adverse outcomes.

The findings support the integration of structured fast-track anaesthesia into cardiac ERAS pathways. Successful implementation depends on appropriate patient selection, short-acting & opioid-sparing anaesthesia, effective multimodal analgesia, optimized cardiopulmonary bypass management, protocolized postoperative care & immediate availability of rescue ventilatory support.

Larger multicentre prospective studies from Indian cardiac centres are required to validate these findings & determine the economic & clinical impact of fast-track cardiac anaesthesia in different patient-risk groups.

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