Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus ...recommendations for the optimal perioperative management of patients undergoing cardiac surgery. A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and reviews was conducted for each protocol element. The quality of the evidence was graded and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery After Surgery Society.
Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the ...United States.
The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre- and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.
Comparing the pre- (N = 489) with the post- (N = 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P < .01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P < .01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P < .05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P < .01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P = not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.
Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.
Using urinary biomarkers to reduce acute kidney injury following cardiac surgery Engelman, Daniel T.; Crisafi, Cheryl; Germain, Michael ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
November 2020, 2020-11-00, Letnik:
160, Številka:
5
Journal Article
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Prediction of acute kidney injury (AKI) following cardiac surgery is unreliable through the use of serum creatinine or urinary output alone. Cell cycle arrest urinary biomarkers insulin-like growth ...factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP2) provide early detection of kidney stress and possibly AKI. We sought to determine whether therapeutic interventions driven by elevated urinary biomarkers (UB) reduces post–cardiac surgery stage 2/3 AKI.
A quality improvement initiative based on UB was undertaken in all adult on-pump cardiac surgical patients with a preoperative serum creatinine level ≤2.0 mg/dL. A UB score the morning after cardiac surgery that was considered positive for kidney stress (≥0.3 ng/mL2/1000) triggered activation of a multidisciplinary acute kidney response team (AKRT) with implementation of a predefined staged protocol, including targeted goal-directed fluid management, liberalized transfusion thresholds, continued invasive hemodynamic monitoring and its optimization in the intensive care unit, and avoidance of nephrotoxins. We compared the incidence of stage 2/3 AKI before (pre-UB) versus after (post-UB) implementation of the Kidney Disease: Improving Global Outcomes quality improvement initiative. Standardized, protocolized, evidence-based care pathways were used pre-UB.
The incidence of stage 2/3 AKI was compared in 435 pre-UB patients and 412 post-UB patients. Fifty-five percent of the post-UB patients had a moderate or high UB score (≥0.3 ng/mL2/1000). Ten patients (2.30%) had stage 2/3 AKI pre-UB, compared with 1 patient (0.24%) post-UB, a relative reduction of 89% (P = .01). The total and postoperative lengths of stay, cost, mortality, and readmissions were similar in the 2 groups. The negative predictive value for AKI of UB <0.3 ng/mL2/1000 was 100%.
The routine measurement of UB and subsequent activation of an AKRT are useful post–cardiac surgery therapeutic adjuncts. They are associated with early detection of kidney stress, allowing for targeted proactive intervention, and a significant decrease in postoperative stage 2/3 AKI without increases in cost or length of stay.
Response to urinary biomarkers drawn the morning after cardiac surgery. Display omitted
In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national ...landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.
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The standard of care: ‘standardized care’ Salenger, Rawn; Engelman, Daniel T
European journal of cardio-thoracic surgery,
05/2023, Letnik:
63, Številka:
5
Journal Article
Commentary: The need for better identification of postoperative delirium Chatterjee, Subhasis; Engelman, Daniel T.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
February 2022, 2022-02-00, 20220201, Letnik:
163, Številka:
2
Journal Article
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