Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery

PURPOSE OF REVIEW

This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery.

RECENT FINDINGS

Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing.

SUMMARY

Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Ambulatory anesthesia: restructuring for success

PURPOSE OF REVIEW

We review current evidence about organizational structures, patient selection criteria, safety measures, economic considerations, quality management, and staffing challenges in ambulatory anesthesia. The focus is on the facilitators and barriers related to the peri-interventional period and the potential concepts and innovations for the future development of ambulatory anesthesia services.

RECENT FINDINGS

Recent findings shed light on organizational structures in ambulatory anesthesia, including hospital-based centers, freestanding ambulatory centers, and office-based practices. Patient selection for ambulatory anesthesia involves a two-step process, considering both surgical and anesthetic factors. Safety measures, such as standardized guidelines and scoring systems, aim to ensure patient well being during the perioperative course. Economic considerations pose challenges due to the complexities of managing operating room efficiency and the variations in reimbursement systems. Quality management in ambulatory anesthesia emphasizes the need for outcome studies and patient-centered quality indicators. Staffing requirements necessitate highly skilled professionals with both technical and nontechnical skills, and structured education and training are essential.

SUMMARY

Ambulatory anesthesia is gaining importance due to advancements in surgical techniques and peri-interventional care. The review highlights the need for addressing challenges related to organizational structures, patient selection, patient safety, economic considerations, quality management, and staffing in ambulatory anesthesia. Understanding and addressing these factors are crucial for promoting the further development and improvement of ambulatory anesthesia services.

Characterizing Decision-Making Surrounding Exercise in ARVC: Analysis of Decisional Conflict, Decisional Regret, and Shared Decision-Making

BACKGROUND

Limiting high-intensity exercise is recommended for patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) due to its association with penetrance, arrhythmias, and structural progression. Guidelines recommend shared decision-making (SDM) for exercise level, but there is little evidence regarding its impact. Therefore, we sought to evaluate the extent and implications of SDM for exercise, decisional conflict, and decisional regret in patients with ARVC and at-risk relatives.

METHODS

Adults diagnosed with ARVC or with positive genetic testing enrolled in the Johns Hopkins ARVC Registry were invited to complete a questionnaire that included exercise history and current exercise, SDM (SDM-Q-9), decisional conflict, and decisional regret.

RESULTS

The response rate was 64.8%. Two-thirds of participants (68.0%, n=121) reported clinically significant decisional conflict regarding exercise at diagnosis/genetic testing (DCS [decisional conflict scale]≥25), and half (55.1%, n=98) in the past year. Prevalence of decisional regret was also high with 55.3% (n=99) reporting moderate to severe decisional regret (DRS [decisional regret scale]≥25). The extent of SDM was highly variable ranging from no (0) to perfect (100) SDM (mean, 59.6±25.0). Those diagnosed in adolescence (≤age 21) reported significantly more SDM (P=0.013). Importantly, SDM was associated with less decisional conflict (ß=-0.66, R2=0.567, P<0.01) and decisional regret (ß=-0.37, R2=0.180, P<0.001) and no difference in vigorous intensity aerobic exercise in the 6 months after diagnosis/genetic testing or the past year (P=0.56; P=0.34, respectively).

CONCLUSIONS

SDM is associated with lower decisional conflict and decisional regret; and no difference in postdiagnosis exercise. Our data thus support SDM as the preferred model for exercise discussions for ARVC.

Shared Decision-Making in Acute Pain Services

PURPOSE OF REVIEW

The implementation of shared decision-making (SDM) in acute pain services (APS) is still in its infancies especially when compared to other medical fields.

RECENT FINDINGS

Emerging evidence fosters the value of SDM in various acute care settings. We provide an overview of general SDM practices and possible advantages of incorporating such concepts in APS, point out barriers to SDM in this setting, present common patient decisions aids developed for APS and discuss opportunities for further development. Especially in the APS setting, patient-centred care is a key component for optimal patient outcome. SDM could be included into everyday clinical practice by using structured approaches such as the "seek, help, assess, reach, evaluate" (SHARE) approach, the 3 "MAking Good decisions In Collaboration"(MAGIC) questions, the "Benefits, Risks, Alternatives and doing Nothing"(BRAN) tool or the "the multifocal approach to sharing in shared decision-making"(MAPPIN'SDM) as guidance for participatory decision-making. Such tools aid in the development of a patient-clinician relationship beyond discharge after immediate relief of acute pain has been accomplished. Research addressing patient decision aids and their impact on patient-reported outcomes regarding shared decision-making, organizational barriers and new developments such as remote shared decision-making is needed to advance participatory decision-making in acute pain services.

Prehabilitation in Cardiovascular Surgery: The Effect of Neuromuscular Electrical Stimulation (Randomized Clinical Trial)

OBJECTIVE

We aimed to determine the effects of prehabilitation with neuromuscular electrical stimulation (NMES) on muscle status and exercise capacity in patients before cardiac surgery.

METHODS

Preoperative elective cardiac surgery patients were randomly assigned to the NMES group or control group. Intervention in the NMES group was 7-10 sessions, whereas the control group carried out breathing exercises and an educational program. The outcome measures included a six-minute walk test (6MWT) and a muscle status assessment (knee extensor strength (KES), knee flexor strength (KFS), and handgrip strength (HS)) after the course of prehabilitation.

RESULTS

A total of 122 patients (NMES, n = 62; control, n = 60) completed the study. During the NMES course, no complications occurred. After the course prehabilitation KES, KFS, and 6MWT distance were significantly increased (all p < 0.001) in the NMES group compared to the control. There was no significant difference in HS before surgery.

CONCLUSIONS

A short-term NMES course before cardiac surgery is feasible, safe, and effective to improve preoperative functional capacity (six-minute walk distance) and the strength of stimulated muscles.

Modern preoperative evaluation in ambulatory surgery - who, where and how?

PURPOSE OF REVIEW

Ambulatory surgery is increasingly performed in medically complex patients. This dynamic environment requires new approaches to ensure cost-effective, efficient, and ultimately safe preoperative evaluation of the patient. This review investigates recent advances in the assessment of ambulatory patients, with a special focus on patient screening, digital communication, and multidisciplinary team evaluation.

RECENT FINDINGS

Identifying suitable candidates for ambulatory surgery relies on a variety of medical, surgical, and institutional factors. Identification of high-risk patients and optimization of their treatment can be achieved through multidisciplinary protocols specific to the local institution and in line with current guidelines. Virtual assessment may be sufficient for most patients and provide an efficient evaluation strategy and high patient satisfaction. Prescreening can be supported by preoperative nursing teams.

SUMMARY

The increasing complexity of treatment provided in day surgery offers a unique opportunity to highlight the importance of anesthesiology staff as perioperative caregivers. Preoperative evaluation serves as a central junction to integrate a variety of surgical, medical, and institutional factors to provide safe, satisfactory, and efficient care for patients. Implementing technological innovation to streamline and facilitate this process is paramount.

Machine learning-based prediction of massive perioperative allogeneic blood transfusion in cardiac surgery

BACKGROUND

Massive perioperative allogeneic blood transfusion, that is, perioperative transfusion of more than 10 units of packed red blood cells (pRBC), is one of the main contributors to perioperative morbidity and mortality in cardiac surgery. Prediction of perioperative blood transfusion might enable preemptive treatment strategies to reduce risk and improve patient outcomes while reducing resource utilisation. We, therefore, investigated the precision of five different machine learning algorithms to predict the occurrence of massive perioperative allogeneic blood transfusion in cardiac surgery at our centre.

OBJECTIVE

Is it possible to predict massive perioperative allogeneic blood transfusion using machine learning?

DESIGN

Retrospective, observational study.

SETTING

Single adult cardiac surgery centre in Austria between 01 January 2010 and 31 December 2019.

PATIENTS

Patients undergoing cardiac surgery.

MAIN OUTCOME MEASURES

Primary outcome measures were the number of patients receiving at least 10 units pRBC, the area under the curve for the receiver operating characteristics curve, the F1 score, and the negative-predictive (NPV) and positive-predictive values (PPV) of the five machine learning algorithms used to predict massive perioperative allogeneic blood transfusion.

RESULTS

A total of 3782 (1124 female:) patients were enrolled and 139 received at least 10 pRBC units. Using all features available at hospital admission, massive perioperative allogeneic blood transfusion could be excluded rather accurately. The best area under the curve was achieved by Random Forests: 0.810 (0.76 to 0.86) with high NPV of 0.99). This was still true using only the eight most important features [area under the curve 0.800 (0.75 to 0.85)].

CONCLUSION

Machine learning models may provide clinical decision support as to which patients to focus on for perioperative preventive treatment in order to preemptively reduce massive perioperative allogeneic blood transfusion by predicting, which patients are not at risk.

TRIAL REGISTRATION

Johannes Kepler University Ethics Committee Study Number 1091/2021, Clinicaltrials.gov identifier NCT04856618.

Effect of Perioperative Lipid Status on Clinical Outcomes after Cardiac Surgery

Patients undergoing cardiac surgery are at increased cardiovascular risk, which includes altered lipid status. However, data on the effect of cardiac surgery and cardiopulmonary bypass (CPB) on plasma levels of key lipids are scarce. We investigated potential effects of CPB on plasma lipid levels and associations with early postoperative clinical outcomes. This is a prospective bio-bank study of patients undergoing elective cardiac surgery at our center January to December 2019. The follow-up period was 1 year after surgery. Blood sampling was performed before induction of general anesthesia, upon weaning from cardiopulmonary bypass (CPB), and on the first day after surgery. Clinical end points included the incidence of postoperative stroke, myocardial infarction, and death of any cause at 30 days after surgery as well as 1-year all-cause mortality. A total of 192 cardiac surgery patients (75% male, median age 67.0 years (interquartile range 60.0-73.0), median BMI 26.1 kg/m² (23.7-30.4)) were included. A significant intraoperative decrease in plasma levels compared with preoperative levels (all p < 0.0001) was observed for total cholesterol (TC) (Cliff's delta d: 0.75 (0.68-0.82; 95% CI)), LDL-Cholesterol (LDL-C) (d: 0.66 (0.57-0.73)) and HDL-Cholesterol (HDL-C) (d: 0.72 (0.64-0.79)). At 24h after surgery, the plasma levels of LDL-C (d: 0.73 (0.650.79)) and TC (d: 0.77 (0.69-0.82)) continued to decrease compared to preoperative levels, while the plasma levels of HDL-C (d: 0.46 (0.36-0.55)) and TG (d: 0.40 (0.29-0.50)) rebounded, but all remained below the preoperative levels (p < 0.001). Mortality at 30 days was 1.0% (N = 2/192), and 1-year mortality was 3.8% (N = 7/186). Postoperative myocardial infarction occurred in 3.1% of patients (N = 6/192) and postoperative stroke in 5.8% (N = 11/190). Adjusting for age, sex, BMI, and statin therapy, we noted a protective effect of postoperative occurrence of stroke for pre-to-post-operative changes in TC (adjusted odds ratio (OR) 0.29 (0.07-0.90), p = 0.047), in LDL-C (aOR 0.19 (0.03-0.88), p = 0.045), and in HDL-C (aOR 0.01 (0.00-0.78), p = 0.039). No associations were observed between lipid levels and 1-year mortality. In conclusion, cardiac surgery induces a significant sudden drop in levels of key plasma lipids. This effect was pronounced during the operation, and levels remained significantly lowered at 24 h after surgery. The intraoperative drops in LDL-C, TC, and HDL-C were associated with a protective effect against occurrence of postoperative stroke in adjusted models. We demonstrate that the changes in key plasma lipid levels during surgery are strongly correlated, which makes attributing the impact of each lipid to the clinical end points, such as postoperative stroke, a challenging task. Large-scale analyses should investigate additional clinical outcome measures.

Many steps can be taken to enhance recovery after thoracic surgery

Our letter to the editor comments on issues raised in the May 14, 2020, article by Budacan et al. addressing the development of enhanced recovery after thoracic surgery. In the United Kingdom and Ireland, a nationwide survey identified issues. Here, we expand on the authors’ findings.

Providing safe perioperative care in cardiac surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.

Anaesthesia for minimally invasive cardiac procedures in the catheterization lab

PURPOSE OF REVIEW

The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures.

RECENT FINDINGS

The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting.

SUMMARY

Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.

Telemedicine for preoperative assessment during a COVID-19 pandemic: Recommendations for clinical care

Limiting the spread of the disease is key to controlling the COVID-19 pandemic. This includes identifying people who have been exposed to COVID-19, minimizing patient contact, and enforcing strict hygiene measures. To prevent healthcare systems from becoming overburdened, elective and non-urgent medical procedures and treatments have been postponed, and primary health care has broadened to include virtual appointments via telemedicine. Although telemedicine precludes the physical examination of a patient, it allows collection of a range of information prior to a patient's admission, and may therefore be used in preoperative assessment. This new tool can be used to evaluate the severity and progression of the main disease, other comorbidities, and the urgency of the surgical treatment as well as preferencing anesthetic procedures. It can also be used for effective screening and triaging of patients with suspected or established COVID-19, thereby protecting other patients, clinicians and communities alike.