ERAS for Cardiac Surgery

I have been utilizing ERAS in general surgery, OB, and ortho cases.  Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery.  Careful what you look for my friends.  There’s actually a good amount of information out there!

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.  The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852. 

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

From Journal of Anesthesiology

Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 2016 Jun;30(3):665-70. doi: 10.1053/j.jvca.2016.01.017. Epub 2016 Jan 16.

A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19.

Clinical Trial: The Safety and Efficacy of the Enhanced Recovery After Surgery(ERAS) Applied on Cardiac Surgery With Cardiopulmonary Bypass: a Single Center, Randomized, Controlled Clinical Study. May 2017.  

A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery. Ann Thorac Surg 2018;105:1684–90.

Enhanced Recovery After Cardiac Surgery Society

My blog posts:

• Ketamine for intraoperative and postoperative analgesia
• Lidocaine infusions for pain
• Enhanced Recovery After Surgery (ERAS)

Key Points

• Level 1 (Class of recommendation=Strong Benefit):
  • Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
  • Perioperative glycemic control is recommended (BS 70-180; [110-150]).
  • A care bundle of best practices should be performed to reduce surgical site infection.
  • Goal-directed therapy should be performed to reduce postoperative complications.
  • A multimodal, opioid-sparing, pain management plan is recommended postoperatively
  • Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
  • Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
  • Post-operative systematic delirium screening is recommended at least once per nursing shift.
  • An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
  • Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
• Level IIa (Class of recommendation=Moderate Benefit)
  • Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
  • Rigid sternal fixation can be useful to reduce mediastinal wound complications.
  • Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
  • Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
  • Early extubation strategies after surgery are reasonable to be employed.
  • Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
  • Chemical thromboprophylaxis can be beneficial following cardiac surgery.
  • Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
  • Correction of nutritional deficiency, when feasible, can be beneficial.
• Level IIb (Class of recommendation=Weak Benefit)
  • A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
  • Carbohydrate loading may be considered before surgery.

 

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

Volume 32, Issue 6, December 2018, Pages 2760-2770.