Effect of ultra-fast-track cardiac anesthesia on vasoactive-inotropic support after coronary artery bypass grafting

Abstract

Background

Ultra-fast-track cardiac anesthesia (UFTCA) aims to promote rapid tracheal extubation and has increasingly been incorporated into enhanced recovery protocols after coronary artery bypass grafting (CABG). Nevertheless, its influence on early postoperative hemodynamic stability, particularly in terms of vasoactive-inotropic requirements, remains insufficiently defined.

Methods

In this study with a prospective, randomized design, adult patients scheduled for elective isolated CABG were assigned in a 1:1 ratio to either immediate extubation in the operating theater (UFTCA group) or conventional extubation in the intensive care unit (ICU). All participants received standardized general anesthesia combined with ultrasound-guided thoracic paravertebral and femoral nerve blocks. The primary endpoint was the cumulative vasoactive-inotropic score (VIS) within the first 24 hours postoperatively. Secondary endpoints included ICU and hospital length of stay, time to mobilization, chest tube removal, postoperative pain, nausea and vomiting, delirium, and quality of recovery evaluated using the quality of recovery-15 (QoR-15).

Results

Outcome analyses were performed on 98 randomized patients (60.2% male; mean age 63.1±8.4 years) with comparable baseline variables between groups. The UFTCA group demonstrated significantly lower 24-hour cumulative VIS values compared with the conventional extubation group (1.74±1.75 vs. 3.97±2.82; p<0.05). Additionally, ICU and hospital stay durations, time to mobilization, and chest tube removal occurred earlier in the UFTCA cohort. QoR-15 scores were significantly improved in the UFTCA group. Postoperative pain scores, rescue analgesic use, nausea, vomiting, and delirium rates did not differ significantly. No reintubation or respiratory complications were observed following ultra-fast-track management.

Conclusion

Immediate extubation using an UFTCA strategy was associated with reduced vasoactive-inotropic support requirements and improved early recovery metrics after CABG, without compromising safety.

Ultra-fast-track cardiac anesthesia (UFTCA) is a contemporary perioperative strategy designed to facilitate very early tracheal extubation, either in the operating room or within the first few postoperative hours after cardiac surgery.^[1] By reducing the duration of mechanical ventilation (MV) and limiting exposure to long-acting anesthetic agents, this approach has been incorporated into enhanced recovery protocols to support early physiological stabilization and improve perioperative resource utilization.^{[1, 2, 3]} However, despite increasing clinical adoption, its physiological impact on immediate postoperative cardiovascular stability remains insufficiently elucidated.

MV may affect cardiovascular function by increasing intrathoracic pressure, which can reduce venous return and ventricular preload, ultimately influencing cardiac output.^{[4, 5]} These hemodynamic alterations may, in turn, necessitate increased use of vasoactive and inotropic agents to maintain circulatory stability in the early postoperative period. The extent of pharmacologic cardiovascular support can be quantified using the vasoactive-inotropic score (VIS), a validated composite measure of postoperative cardiovascular instability and clinical severity in patients undergoing cardiac surgery.^{[6, 7, 8]}

Although observational studies have suggested that fast-track anesthesia strategies may be associated with more favorable early hemodynamic profiles, high-quality randomized evidence focusing on objective hemodynamic endpoints remains limited, particularly in patients undergoing coronary artery bypass grafting (CABG).^{[1, 9, 10, 11, 12]}

Accordingly, we conducted a randomized clinical trial to evaluate the effect of UFTCA on early vasoactive-inotropic support in patients undergoing isolated elective CABG surgery.

Methods

Study Design and Ethical Approval

This prospective randomized controlled trial was approved by the Institutional Ethics Committee of Harran University (approval number: HRÜ/25.12.01, date: 10.07.2025) and prospectively registered in a publicly accessible clinical trials registry prior to patient enrollment (ClinicalTrials.gov identifier: NCT07207421). The study was conducted between October 2025 and December 2025, during which patient recruitment, interventions, and follow-up were completed. Written informed consent was obtained from all participants before enrollment. The trial was conducted in accordance with the Declaration of Helsinki and internationally accepted ethical standards and was reported in accordance with the consolidated standards of reporting trials guidelines.

Patient Selection

Adult patients aged 18-80 years scheduled for elective on-pump CABG were screened for eligibility. Patients were excluded if they underwent emergency surgery, required combined cardiac procedures (e.g., valve surgery), presented with preoperative shock, required preoperative MV, had severe chronic respiratory disease (Global Initiative for Chronic Obstructive Lung Disease stage III-IV), exhibited significant hepatic dysfunction, had end-stage renal disease requiring chronic dialysis, were pregnant, or lacked the capacity to provide informed consent.

Randomization and Group Allocation

After confirming eligibility, patients were randomly assigned in a 1:1 ratio to either the UFTCA group or the standard extubation group using a computer-generated randomization sequence. Allocation concealment was ensured using sealed, opaque envelopes, which were opened after completion of the surgical procedure.

Group assignment followed standard clinical care pathways, enabling assessment under routine perioperative conditions while maintaining internal validity.

Anesthetic and Analgesic Management

All patients received standardized general anesthesia combined with ultrasound-guided regional anesthesia as part of a multimodal analgesia protocol.

A bilateral ultrasound-guided thoracic paravertebral block at the T4 level was performed in the sitting position prior to induction of general anesthesia. A high-frequency linear ultrasound transducer was placed approximately 2 cm lateral to the midline to visualize the transverse process, costotransverse ligament, and pleura. After confirmation of correct needle placement within the paravertebral space, 20 mL of 0.25% bupivacaine was administered.

Following induction and positioning of the patient in the supine position, an ultrasound-guided femoral nerve block was performed within the femoral triangle. The femoral artery, femoral nerve, and iliopsoas muscle were identified, and 10 mL of 0.25% bupivacaine was injected perineurally (Figure 1).

Figure 1.

Ultrasound-guided paravertebral and femoral nerve blocks.

All patients were managed according to a standardized institutional anesthesia and perioperative care protocol. Anesthesia was induced with propofol (1-2 mg/kg) and fentanyl (1.5-2 µg/kg), and neuromuscular blockade was achieved using rocuronium (0.6 mg/kg). Maintenance of anesthesia was achieved using volatile anesthetic agents (sevoflurane).

MV was conducted using a lung-protective strategy, including low tidal volumes (5-7 mL/kg), a respiratory rate of 12-15 breaths/min, and a driving pressure maintained below 15 cmH₂O, with positive end-expiratory pressure set at 5-10 cmH₂O.

Intraoperative hemodynamic management, including the administration of vasoactive agents, was guided by institutional protocols and applied uniformly across both study groups.

Postoperatively, all patients received intravenous paracetamol (1 g) at 6-hour intervals as baseline analgesia. Intravenous tramadol (100 mg) was administered as rescue analgesia when the visual analog scale score exceeded 4.

The analgesic regimen was identical in both groups, and no additional analgesic interventions were provided based on group allocation.

Surgical Technique

Patients were positioned supine and underwent general anesthesia. A standard median sternotomy was performed. The left internal mammary artery (LIMA) was harvested as a pedicled graft, and distal flow was assessed. Following systemic heparinization (350-400 IU/kg), the distal LIMA was clipped and preserved with papaverine for subsequent use.

In parallel, the right great saphenous vein was harvested using standard techniques. Side branches were ligated, and the graft was distended with heparinized saline.

After achieving an activated clotting time >480 seconds, arterial and venous cannulation was performed, and cardiopulmonary bypass (CPB) was initiated. The aorta was cross-clamped, and cardiac arrest was induced using antegrade cold blood cardioplegia. Mild systemic hypothermia (32-34 °C) and topical myocardial cooling were maintained throughout CPB.

Distal coronary anastomoses were performed sequentially (right coronary artery, circumflex, and diagonal branches) using 7-0 polypropylene sutures, followed by LIMA-left anterior descending anastomosis using 8-0 polypropylene sutures. After each distal anastomosis, cardioplegia was administered to ensure myocardial protection and hemostasis. Warm blood cardioplegia was subsequently delivered via the saphenous grafts to facilitate rewarming, after which the aortic cross-clamp was removed.

Proximal saphenous vein anastomoses were completed using 6-0 polypropylene sutures under partial aortic occlusion. Following successful weaning from CPB and confirmation of stable hemodynamics and sinus rhythm, heparin was reversed with protamine. Cannulas were removed, hemostasis was secured, and the sternum, subcutaneous tissue, and skin were closed in a standard layered fashion.

Extubation Strategy

In the UFTCA group, tracheal extubation was performed in the operating room immediately after completion of surgery, provided predefined extubation criteria were fulfilled. These criteria included adequate level of consciousness with the ability to follow verbal commands, hemodynamic stability without escalating vasoactive support, normothermia (core temperature ≥36 °C), and adequate spontaneous ventilation (respiratory rate 10-30 breaths/min, peripheral oxygen saturation ≥94% with an inspired oxygen fraction ≤0.4, and end-tidal carbon dioxide ≤45 mmHg), in addition to the absence of significant bleeding or surgical complications.

In the conventional group, patients were transferred to the intensive care unit (ICU) and extubated according to routine ICU practice based on clinical judgment.

Although timing of extubation is influenced by multiple perioperative factors, all modifiable variables were standardized between groups, allowing isolated assessment of the extubation strategy.

Postoperative Hemodynamic Management

Fluid therapy was guided by dynamic preload indices (stroke volume variation and/or clinical assessment) to maintain euvolemia. Cardiac index was continuously monitored and maintained at ≥2.2 L/min/m². Vasoactive and inotropic agents were initiated when mean arterial pressure remained <65 mmHg or when cardiac index fell below target despite adequate volume optimization. Norepinephrine was used as the first-line vasoactive agent, with additional inotropes administered according to standardized institutional protocols. All interventions were applied uniformly across both study groups.

Vasoactive support was titrated according to a standardized institutional protocol targeting predefined hemodynamic goals, with no differences in management strategy between groups.

Outcome Measures

The primary outcome was the VIS, calculated as the cumulative VIS during the first 24 postoperative hours.

The cumulative VIS was determined by applying standard weighting coefficients to each vasoactive agent, as follows:

VIS = (dopamine dose [µg/kg/min]) + (dobutamine dose [µg/kg/min]) + 100 × (epinephrine dose [µg/kg/min]) + 100 × (norepinephrine dose [µg/kg/min]) + 10 × (milrinone dose [µg/kg/min]) + 10,000 × (vasopressin dose [µg/kg/min]).

Vasoactive drug doses were recorded hourly during the first 24 postoperative hours in the ICU. VIS was calculated at each time point using the standard formula. The cumulative VIS was defined as the sum of hourly VIS values over the 24-hour period, thereby reflecting the overall vasoactive support requirement over time rather than isolated peak measurements. This approach was adopted to better characterize the dynamic nature of vasoactive support.

Secondary outcomes included postoperative analgesic consumption, duration of ICU stay, total hospital length of stay, incidence of postoperative nausea and vomiting, postoperative delirium, time to first mobilization, time to chest drain removal, and postoperative recovery status assessed using the quality of recovery-15 (QoR-15).

The Confusion Assessment Method for the ICU was used to screen for postoperative delirium. Assessments were performed by trained clinicians at regular intervals during the first 48 postoperative hours or until ICU discharge.

All data were obtained from continuous electronic monitoring systems and standardized ICU patient observation charts. No clinically significant missing data were identified during the study period.

Blinding

Because of the inherent characteristics of the intervention, anesthesiologists and ICU staff could not be blinded to group allocation. However, outcome assessments and statistical analyses were conducted by investigators who were blinded to treatment assignment.

Statistical Analysis

The sample size calculation was based on pilot study data. A pilot study was used instead of previously published literature because no directly comparable studies had reported VIS outcomes in the setting of UFTCA and early extubation among patients undergoing on-pump CABG. Pilot data demonstrated mean 24-hour cumulative VIS scores of 2.18±1.82 in the UFTCA group and 3.79±3.44 in the control group. On the basis of these findings, a sample size of 44 patients per group was calculated to provide 80% statistical power at a significance level of 0.05. To compensate for potential dropouts, 50 patients were enrolled in each group.

Data normality was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. Differences in quantitative variables between groups were analyzed using either parametric (independent-samples t-test) or non-parametric (Mann-Whitney U test) methods, depending on data distribution. Qualitative variables were analyzed using the chi-square test. Statistical analyses were performed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 100 patients were screened for eligibility; however, two patients were excluded before randomization because of ineligibility (n=1) or withdrawal of consent (n=1). Consequently, 98 patients were randomly assigned in equal proportions to either the UFTCA group (n=49) or the standard extubation management group (n=49).

All randomized patients received the allocated intervention. In the UFTCA group, all patients were successfully extubated in the operating theater as planned, whereas patients in the conventional management group were transferred to the ICU while intubated and subsequently extubated according to standard clinical practice. Accordingly, all 49 patients in each group were included in the final analysis (Figure 2).

Figure 2.

CONSORT flow diagram of patient enrollment, allocation, and analysis.

CONSORT: Consolidated standards of reporting trials; UFTCA: Ultra-fast-track cardiac anesthesia.

Outcome analyses were conducted for all 98 randomized patients, including 59 men (60.2%) and 39 women (39.8%). The mean age of the overall cohort was 63.1±8.4 years. Reported comorbidities included diabetes mellitus in 41.8% of patients (n=41), hypertension in 36.7% (n=36), and chronic obstructive pulmonary disease in 19.3% (n=19).

Baseline demographic characteristics, preoperative ejection fraction, CPB duration, and aortic cross-clamp time were comparable between the two groups, with no statistically significant differences observed (p>0.05) (Table 1).

Table 1. Baseline demographic and clinical characteristics.

-		Control group (n=49)			UFTCA group (n=49)			p
		Mean ± SD/n-%			Mean ± SD/n-%			-
Age		62.7	±	8.6	63.5	±	8.3	0.647t
Gender	Female	21	-	42.8%	19	-	38.7%	0.615X²
	Male	28	-	57.1%	30	-	61.2%
Diabetes mellitus		19	-	38.7%	22	-	44.8%	0.595X²
Hypertension		15	-	30.6%	21	-	42.8%	0.234X²
COPD	-	10	-	20.4%	9	-	18.3%	0.758X²
CRF	-	4	-	8.1%	4	-	8.1%	0.975X²
CVD	-	4	-	8.1%	3	-	6.1%	0.663X²
Ejection fraction (%)		51.9	±	8.7	50.2	±	7.1	0.121m
CPB time (min)		97.3	±	17.5	101.8	±	13.1	0.167m
Cross-clamp time (min)		63.2	±	12.8	65.6	±	13.2	0.527m

UFTCA: Ultrafast-track cardiac anesthesia; COPD: Chronic obstructive pulmonary disease; CRF: Chronic renal failure; SD: Standard deviation; CVD: Cerebrovascular disease; CPB: Cardiopulmonary bypass; ^m: Mann-Whitney U test; ^X²: Chi-square test; min: Minutes.

Evaluation of the primary outcome demonstrated that cumulative VIS during the first 24 postoperative hours was significantly lower in the UFTCA group than in the conventional extubation group (1.74±1.75 vs. 3.97±2.82, p<0.05) (Table 2).

Table 2. Primary outcome and hemodynamic results.

-	Control group (n=49)			UFTCA group (n=49)			p
	Mean ± SD/n-%			Mean ± SD/n-%			-
VIS score	3.97	±	2.82	1.74	±	1.75	<0.001m*

UFTCA: Ultrafast-track cardiac anesthesia; VIS: Vasoactive-inotropic score; ^m: Mann-Whitney U test; SD: Standard deviation.

Analysis of secondary outcomes showed that patients in the UFTCA group experienced a shorter ICU stay, reduced total hospital length of stay, and earlier mobilization compared with those in the conventional group (p<0.05). Furthermore, QoR-15 scores demonstrated superior postoperative recovery quality in the UFTCA group (p<0.05) (Table 3).

Table 3. Postoperative recovery and secondary outcomes.

-	Control group (n=49)		UFTCA group (n=49)
	Mean ± SD/n-%		Mean ± SD/n-%				p
QoR-15 score	126.3	±	10.1	135.5	±	6.7	<0.001m*
Extubation time (h)	7.96	±	2.61	0	±	0	<0.001m*
First mobilizaiton time (h)	21.6	±	5.7	14.6	±	4.9	<0.001m*
Chest drain removal time (h)	31.6	±	10.8	24.5	±	8.3	<0.001m*
ICU length of stay (d)	3.2	±	1.1	2.3	±	0.8	<0.001m*
Hospital length of stay (d)	9.2	±	3.1	7.5	±	1.8	<0.001m*

UFTCA: Ultrafast-track cardiac anesthesia; QoR: Quality of recovery; ICU: Intensive care unit; ^m: Mann-Whitney U test; h: Hours; d: Days; SD: Standard deviation.

Postoperative analgesic outcomes were comparable between the two groups, with no statistically significant differences observed in pain scores or rescue tramadol consumption (p>0.05). Likewise, the incidences of postoperative nausea and vomiting and postoperative delirium were similar between groups, with no significant differences detected (p>0.05) (Table 4).

Table 4. Analgesic outcomes and postoperative complications.

-	Control group (n=49)				UFTCA group (n=49)			p
-	Mean ± SD/n-%				Mean ± SD/n-%
VAS at 2nd h VAS at 4th h VAS at 8th h VAS at 16th h VAS at 24th h	-	0.68	±	0.91	0.54	±	1.01	0.236m 0.454m 0.579m 0.616m 0.440m
	-	0.62	±	0.97	0.50	±	0.90
	-	1.15	±	1.14	1.04	±	1.17
	-	2.00	±	1.90	1.83	±	1.51
	-	2.43	±	2.14	2.19	±	1.99
Tramadol use (number of doses in first 24 hours)	0	38	±	77.5%	35	-	71.4%	0.359
	1	4	±	8.1%	11	-	22.4%
	2	3	±	6.1%	1	-	2.04%
	3	2	±	4.08%	-	-	2.04%
Nausea Vomiting Delirium	-	7	-	14.2%	7	-	14.2%	0.966X² 0.751X² 0.170X²
	-	4	-	8.1%	5	-	10.2%
	-	7	-	14.2%	3	-	6.1%

UFTCA: Ultrafast-track cardiac anesthesia; SD: Standard deviation; VAS: Visual analog scale; ^m: Mann-Whitney U test; X²: Chi-square test; h: Hours.

No block-related complications, including nerve injury, hematoma, local anesthetic systemic toxicity, or pneumothorax, were observed in either group. In the UFTCA group, no postoperative respiratory complications or reintubations occurred. In-hospital mortality was reported in one patient from each group.

Discussion

With the increasing global burden of cardiac surgery, perioperative strategies aimed at accelerating recovery and optimizing resource utilization have gained substantial importance. Among these strategies, UFTCA, which facilitates extubation in the operating theater or within the first postoperative hour, has emerged as an integral component of contemporary perioperative care pathways. Previous studies have demonstrated that UFTCA may reduce ICU and hospital length of stay while improving cost-effectiveness in selected cardiac surgical populations.^{[1, 13]}

In this randomized clinical study involving patients undergoing isolated CABG procedures, implementation of a UFTCA protocol was associated with significantly shorter ICU and hospital stays as well as earlier chest drain removal. These findings are consistent with those reported by Jiang et al.,^[14] who observed reductions in hospitalization duration and postoperative delirium among patients managed with UFTCA. Collectively, these findings support the hypothesis that early extubation strategies may positively influence early postoperative recovery trajectories following CABG surgery.

Enhanced recovery after cardiac surgery (ERACS) protocols advocate a multidisciplinary and standardized approach to perioperative optimization, with particular emphasis on early awakening, timely extubation, and accelerated mobilization.^{[3, 15]} Within this framework, UFTCA represents a central component of perioperative recovery pathways. Importantly, unlike several previous studies in which regional analgesia was administered only to early extubation groups,^{[1, 14]} both groups in the present study received the same multimodal analgesic regimen. The absence of significant differences in postoperative pain scores and rescue analgesic requirements between groups suggests that the observed improvements in recovery parameters were unlikely to have been confounded by variations in analgesic management. This methodological approach further strengthens the internal validity of the study findings.

Furthermore, the inclusion of a femoral nerve block in the analgesic protocol was based on the recognition that saphenous vein harvesting is a major contributor to postoperative pain following CABG.^{[16, 17]} Although this technique is not routinely included in standard analgesic strategies for median sternotomy procedures, targeted management of lower limb pain may improve overall patient comfort, facilitate earlier mobilization, and support the principles of ERACS.^{[3, 18]}

The VIS has emerged as a validated indicator of early postoperative cardiovascular instability and illness severity in cardiac surgical patients.^{[7, 19, 20]} Elevated VIS values have been associated with increased morbidity and adverse postoperative outcomes, including acute kidney injury and prolonged MV.^[21] Conversely, lower VIS values have been proposed as a physiological correlate of successful early extubation strategies.^[22] Consistent with these findings, the present study demonstrated significantly lower VIS values in the UFTCA group. These results suggest that early extubation may reduce postoperative hemodynamic support requirements, potentially through the restoration of more physiological intrathoracic pressure dynamics and improved ventricular loading conditions.

It is important to acknowledge several limitations of this study. First, its single-center design may limit the generalizability of the findings to institutions with different patient populations and perioperative practices. Second, blinding of clinical staff was not feasible, which may have introduced performance bias. Third, although standardized extubation criteria were strictly applied, clinical judgment inevitably influenced decision-making. Finally, although VIS provides an integrated measure of vasoactive support, it does not capture short-term fluctuations in hemodynamic requirements.

In this randomized controlled study of patients undergoing isolated CABG, implementation of a UFTCA protocol was associated with reduced 24-hour vasoactive-inotropic requirements, shorter ICU and hospital length of stay, earlier chest drain removal, and improved postoperative recovery quality. When applied within a standardized multimodal analgesic framework, UFTCA enabled safe early extubation without an increase in respiratory complications or reintubation rates. These findings support the incorporation of UFTCA into structured perioperative recovery pathways and highlight the 24-hour cumulative VIS as a practical marker of early postoperative hemodynamic recovery in cardiac surgical patients.

Ethics

Ethics Committee Approval: This prospective randomized controlled trial was approved by the Institutional Ethics Committee of Harran University (approval number: HRÜ/25.12.01, date: 10.07.2025) and prospectively registered in a publicly accessible clinical trials registry prior to patient enrollment (ClinicalTrials.gov identifier: NCT07207421).

Informed Consent: Written informed consent was obtained from all participants before enrollment.