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!
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.
The case is booked as an Ivor-Lewis esophagectomy. Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.
Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.
Case:
40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior. Presented to ED with N/V, epigastric pain, malnourishment. Had underone chemo and radiation. PMH achalasia, endometriosis. NKDA. Scheduled for Ivor-Lewis esophagectomy. Pt appeared cachectic, on TPN, 45kg, 5’5″. L chest port-a-cath in place.
In OR, pt received T7 epidural. RSI w cricoid pressure throughout. 37Fr L DLT placed gently without resistance. 31cm at teeth noted after fiberoptic bronch check. 20g L radial a-line placed. Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP. FloTrac for SVI, SVR, SVV, CO.
Albumin for IVF. Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90. OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor). BIS goal 40-60. Epidural initially dosed with 5ml 2% lido with epi. Another dose given roughly 30 minutes later. Remaining dosing throughout case with 4ml 0.25% bupi. Acetaminophen IV 1000mg prior to incision. Fentanyl IV for abdominal laparoscopy.
Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy. Converted to laparotomy. Tumor adhered to pericardium.
R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg). Good lung isolation. Good anastamosis of tissues. Two lung ventilation according to surgeon. Recruit lungs to decrease atelectasis.
Emergence: + Pressure support through DLT. Extubate in OR.
Lessons learned:
Early communication with surgeon(s).
Lung-protective strategies
Volume restriction for IVF
Appropriate pressor choice
Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above. If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon). Continue baseline pain regimen if patient is a chronic pain patient.
Setup is key. Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.
I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.
I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.
This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.
Ketamine: (different doses I’ve seen in the literature below)
• Induction: 0.2-0.5 mg/kg
• Infusion: 0.1mg/kg/hr before incision
◦ 2mcg/kg/hr x 24hr (spine)
◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)
◦ 2mcg/kg/min
◦ 2-8mcg/kg/min
What I’m using nowadays:
Oct 2017:
Cardiac open hearts: induction bolus=0.5mg/kg + infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved. Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol. Patients are more comfortable and require less pain medication.
Dec 2018:
Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming; infusion 0.2 mg/kg/hr stopping when last dressing placed.
July 2019:
Cardiac open hearts: induction bolus = 1 mg/kg + 0.5mg/kg bolus pre-CPB. No infusion. This formula is roughly in between the bolus (0.5mg/kg) + infusion (0.1mg/kg/hr and 0.2mg/kg/hr) for <5hr case. For hearts >5hr, add 0.25-0.5mg/kg bolus when re-warming (0.5mg/kg dosing roughly approximates a 7hr case).
Sept 2019:
Cardiac open hearts: No induction bolus. 1mg/kg bolus prior to incision. 0.5mg/kg bolus pre-CPB. 0.25-0.5mg/kg bolus rewarming on CPB based on length of case (see July 2019 notes).
Question 1: Which patients and acute pain conditions should be considered for ketamine treatment? Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain? Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia? Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings? Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
Question 5: What is the evidence to support nonparenteral ketamine for acute pain management? Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain? Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.
The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.
Ketamine is an N-methyl-d-aspartate receptor antagonist that is commonly used as an adjunct for the treatment of acute postoperative or posttraumatic pain to improve pain scores and reduce opioid consumption by approximately 30-50%.[46] Certain patients seem to benefit more from the addition of ketamine, including those with chronic neuropathic pain, opioid dependence or tolerance and acute hyperalgesia.[47] 8% of administered ketamine is metabolized by the liver forming norketamine, which possess only 20-30% of the potency of ketamine. Norketamine is then hydroxylated into a water-soluble metabolite excreted by the kidney.[48] Most clinicians believe that dose modification for ketamine is not required for patients with decreased renal function.[48,49
Infusion: 2-3mg/kg/hr after induction to end surgery
If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.
July 2019
I am currently not using lidocaine infusions as my open heart patients are getting great relief with ketamine. I also came across some literature that said lidocaine infusions do not help postoperative cognitive decline. However, I may reassess this at a later time and reinstitute. We do not currently have an acute pain service. Look at the ASRA, May 2017 issue, I do like the dosing regimen used at UVA. See below.
In our institution, an infusion rate of 40 mcg/kg/min after 1–1.5 mg/kg bolus is used perioperatively as part of our ERAS protocols. The infusion rate is decreased to 5–10 mcg/kg/min at the end of the surgery and continues at the same rate until POD 2. Our acute pain management lidocaine infusion protocol uses a 0.5 mg/min starting dose with a maximum of 1 mg/min for adults, and doses between 15 to 25 mcg/kg/min for pediatric patients <40m kg.
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