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Rolfzen ML, Shostrom V, Black T, Liu H, Heiser N, Markin NW. Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00423-3. [PMID: 39030154 DOI: 10.1053/j.jvca.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/23/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVES Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution. DESIGN Retrospective cohort study. SETTING Midwestern academic hospital. PARTICIPANTS Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022. INTERVENTIONS Ultrasound-guided single-injection chest wall block with liposomal bupivacaine. MEASUREMENTS AND MAIN RESULTS Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195). CONCLUSIONS In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.
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Affiliation(s)
- Megan L Rolfzen
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Valerie Shostrom
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Theodore Black
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Haiying Liu
- Department of Anesthesiology, Associated Anesthesiologists, P.C., West Des Moines, IA, USA
| | - Nicholas Heiser
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nicholas W Markin
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA.
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Berger Veith S, Holst T, Erfani S, Pochert J, Dumps C, Girdauskas E, Stock S. Different approach, similar outcomes: the impact of surgical access routes in minimally invasive cardiac surgery on enhanced recovery after surgery. Front Cardiovasc Med 2024; 11:1412829. [PMID: 39011491 PMCID: PMC11247003 DOI: 10.3389/fcvm.2024.1412829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/13/2024] [Indexed: 07/17/2024] Open
Abstract
Objectives Enhanced recovery after surgery (ERAS) is a growing phenomenon in all surgical disciplines and aims to achieve a faster functional recovery after major operations. Minimally invasive cardiac surgery (MICS) therefore integrates well into core ERAS values. Surgical access routes in MICS include right anterolateral mini-thoracotomy (MT) as well as partial upper mini-sternotomy (PS). We seek to compare outcomes in these two cohorts, both of which were enrolled in an ERAS scheme. Methods 358 consecutive patients underwent MICS and perioperative ERAS at our institution between 01/2021 and 03/2023. Patients age >80 years, with BMI > 35 kg/m², LVEF ≤ 35%, endocarditis or stroke with residuum were excluded. Retrospective cohort analysis and statistical testing was performed on the remaining 291 patients. The primary endpoint was successful ERAS, secondary endpoints were the occurrence of major bleeding, ERAS-associated complications (reintubation, return to ICU) as well as access-related complications (wound infection, pleural and pericardial effusions). Results 170 (59%) patients received MT for mitral and/or tricuspid valve surgery (n = 162), closure of atrial septal defect (n = 4) or resection of left atrial tumor (n = 4). The remaining 121 (41%) patients had PS for aortic valve repair/replacement (n = 83) or aortic root/ascending surgery (n = 22) or both (n = 16). MT patients' median age was 63 years (IQR 56-71) and 65% were male, PS patients' median age was 63 years (IQR 51-69) and 74% were male. 251 (MT 88%, PS 83%, p = 0.73) patients passed through the ERAS program successfully. There were three instances of reintubation (2 MT, 1 PS), and three instances of readmission to ICU (2 MT, 1 PS). Bleeding requiring reexploration occurred six times (3 MT, 3 PS). There was one death (PS), one stroke (MT), and one myocardial infarction requiring revascularization (MT). There were no significant differences in any of the post-operative outcomes recorded, except for the incidence of pericardial effusions (MT 0%, PS 3%, p = 0.03). Conclusions Despite different surgical access routes and underlying pathologies, results in both the MT and the PS cohort were generally comparable for the recorded outcomes. ERAS remains safe and feasible in these patient groups.
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Affiliation(s)
- Sarah Berger Veith
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
| | - Theresa Holst
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
| | - Sahab Erfani
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
| | - Julia Pochert
- Department of Anesthesiology and Surgical Intensive Care Medicine, Augsburg University Hospital, Augsburg, Germany
| | - Christian Dumps
- Department of Anesthesiology and Surgical Intensive Care Medicine, Augsburg University Hospital, Augsburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
| | - Sina Stock
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
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Malvindi PG, Bifulco O, Berretta P, Galeazzi M, Alfonsi J, Cefarelli M, Zingaro C, Zahedi HM, Munch C, Di Eusanio M. The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies. J Clin Med 2024; 13:2903. [PMID: 38792445 PMCID: PMC11121940 DOI: 10.3390/jcm13102903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Hossein M. Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
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Schmid ME, Stock S, Girdauskas E. Implementation of an innovative ERAS protocol in cardiac surgery: A qualitative evaluation from patients' perspective. PLoS One 2024; 19:e0303399. [PMID: 38728336 PMCID: PMC11086837 DOI: 10.1371/journal.pone.0303399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols aim to optimize the recovery process for patients after surgical interventions and focus on patient-centered care. In cardiac surgery, the ERAS concept is still in its early stages. Our university hospital has implemented an innovative ERAS protocol for minimally invasive heart valve surgery since 2021. Therefore, our study aimed to comprehensively assess the patient experience within this newly established ERAS protocol and focused on exploring and understanding the nuances of optimal healthcare delivery under the ERAS framework from the unique perspective of the patients undergoing cardiac surgery. METHODS Qualitative research was conducted using semi-structured interviews. Data was analyzed using Kuckartz´s qualitative content analysis. RESULTS The following main themes emerged from the 12 completed patient interviews: 1) information and communication flow, 2) perioperative patient care, and 3) rehabilitation. Patients found the pre-operative patient education and preconditioning very helpful. Patients were satisfied with the flow of information throughout the whole perioperative care process. Most patients expressed a need for more information about the course of surgery. The intensity of care provided by different professions was perceived as optimal. The support and inclusion of relatives in perioperative care were considered crucial. Patients appreciated the direct transfer to the rehabilitation and mainly were able to cope with daily life tasks afterward. CONCLUSION In summary, all patients experienced the ERAS protocol positively, and their healthcare process was well established. Active inclusion and education of patients in their treatment can improve patient empowerment. Two further aspects that deserve major consideration in the healthcare process are the inclusion of relatives and interprofessional cooperation.
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Affiliation(s)
| | - Sina Stock
- Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
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Lobdell KW, Grant MC, Salenger R. Temporary mechanical circulatory support & enhancing recovery after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:16-23. [PMID: 38085881 DOI: 10.1097/aco.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
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.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Michael C Grant
- Johns Hopkins University School of Medicine, Anesthesiology and Critical Care Medicine, Baltimore
| | - Rawn Salenger
- University of Maryland School of Medicine, Department of Surgery, Towson, Maryland, USA
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Delijani D, Race A, Cassiere H, Pena J, Shore-Lesserson LJ, Demekhin V, Manetta F, Huang X, Karman DA, Hartman A, Yu PJ. Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience. J Cardiothorac Vasc Anesth 2024; 38:175-182. [PMID: 37980194 DOI: 10.1053/j.jvca.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution. DESIGN A retrospective cohort study. SETTING This study was a single-institution study conducted at a university hospital. PARTICIPANTS Patients undergoing open adult cardiac surgery. INTERVENTIONS Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented. MEASUREMENTS AND MAIN RESULTS A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts. CONCLUSIONS Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.
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Affiliation(s)
- David Delijani
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Abigail Race
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Hugh Cassiere
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Joseph Pena
- Department of Anesthesia, North Shore University Hospital, Northwell Health, Manhasset, NY
| | | | - Valerie Demekhin
- Department of Pharmacy, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Xueqi Huang
- Department of Biostatistics, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Douglas A Karman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Alan Hartman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Pey-Jen Yu
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY.
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Patel A, Shah A, Apigo A, Lin HM, Ouyang Y, Huang K, Friedman S, Yimen M, Puskas JD, Bhatt HV. Perioperative Implementation of Low-Dose Pregabalin in an Enhanced Recovery After Cardiac Surgery Protocol: A Pre-Post Observational Study. J Cardiothorac Vasc Anesth 2024; 38:183-188. [PMID: 37940456 DOI: 10.1053/j.jvca.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/24/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES Determine the effect of low-dose pregabalin in the perioperative enhanced recovery after cardiac surgery protocol. DESIGN Pre-post observational study. SETTING Tertiary care hospital. PARTICIPANTS Patients undergoing off-pump coronary artery bypass graft procedures. INTERVENTIONS Pregabalin 75 mg BID for 48 hours postoperatively versus no pregabalin in a perioperative setting. MEASUREMENTS AND MAIN RESULTS Perioperative opioid use, pain scores, length of stay, time to extubation, and mortality were all measured. Descriptive data were presented as mean (SD), median (IQR), or N (%). Ordinal and continuous data used the t-test or Kruskal-Wallis test. Categorical data were compared between groups using the chi-square test or Fisher's exact test, as appropriate. Low-dose pregabalin administration (75 mg twice daily for 48 hours after surgery) was associated with a clinically significant reduction in opioid consumption on postoperative day 0 by 30.6%, with a median requirement of 318 (233, 397) morphine milligram equivalents (MME) in the pregabalin group compared with 458 (375, 526) MME in the control group (p < 0.001). There was no significant difference in pain scores between the groups with the exception at 0-to-12 hours, during which the pregabalin group had greater pain scores (median 3.32 [1.65, 4.36] v 2.0 [0, 3.25], p = 0.013) (Table 3). Moreover, there was no significant difference in pain scores on postoperative day 1 (p = 0.492), day 2 (p = 0.442), day 3 (p = 0.237), and day 4 (p = 0.649). The difference in average Richmond Agitation Sedation Score scores was also not statistically significant between groups at 12 hours (p = 0.954) and at 24 hours (p = 0.301). The pregabalin group had no increased incidence of adverse events or any significant differences in intensive care unit length of stay, time to extubation, or mortality. CONCLUSIONS In this evaluation of perioperative pregabalin administration for patients requiring cardiac surgery, pregabalin reduced postoperative opioid use, with significant reductions on postoperative day 0, and without any significant increase in adverse reactions. However, no differences in intensive care unit length of stay, time to extubation, or mortality were noted. The implementation of low-dose perioperative pregabalin within an Enhanced Recovery After Cardiac Surgery protocol may be effective at reducing postoperative opioid use in the immediate postoperative period, and may be safe with regard to adverse events. Ideal dosing strategies have not been determined; thus, further randomized control trials with an emphasis on limiting confounding factors need to be conducted.
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Affiliation(s)
- Alopi Patel
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Morningside Medical Center, New York, NY.
| | - Ami Shah
- Department of Pharmacy, Mount Sinai Morningside Medical Center, New York, NY; Department of Cardiothoracic Surgery and Critical Care, Mount Sinai Morningside Medical Center, New York, NY
| | - Anthony Apigo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Morningside Medical Center, New York, NY
| | - Hung-Mo Lin
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Yuxia Ouyang
- Department of Population Health Science and Policy, Mount Sinai Hospital, New York, NY
| | - Kristy Huang
- Department of Pharmacy, Mount Sinai Morningside Medical Center, New York, NY
| | - Seana Friedman
- Department of Cardiothoracic Surgery and Critical Care, Mount Sinai Morningside Medical Center, New York, NY
| | - Mekeleya Yimen
- Department of Cardiothoracic Surgery and Critical Care, Mount Sinai Morningside Medical Center, New York, NY
| | - John D Puskas
- Department of Cardiothoracic Surgery and Critical Care, Mount Sinai Morningside Medical Center, New York, NY
| | - Himani V Bhatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Morningside Medical Center, New York, NY
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Ma Y, Sui D, Yang S, Yang X, Oldam J, Semel JL, Wang Z, Fang N. Optimal postoperative delirium prediction after coronary artery bypass grafting surgery: a prospective cohort study. Front Cardiovasc Med 2023; 10:1251617. [PMID: 38144372 PMCID: PMC10739452 DOI: 10.3389/fcvm.2023.1251617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
Background Postoperative delirium (POD) presents as a serious neuropsychiatric syndrome in patients undergoing off-pump coronary artery bypass grafting (OPCABG) surgery. This is correlated with higher mortality, cognitive decline, and increased costs. The Age-adjusted Charlson Comorbidity Index (ACCI) is recognized as an independent predictor for mortality and survival rate. The purpose of our study is to estimate the predictive value of the ACCI on the POD in patients undergoing OPCABG surgery. Methods This prospective cohort study enrolled patients undergoing OPCABG surgery between December 2020 and May 2021 in Qilu Hospital. Patients were divided into the low-ACCI group (score, 0-3) and the high-ACCI group (score ≥4) according to their ACCI scores. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and CAM were used to diagnose POD within 7 days after surgery. The general, laboratory, and clinical data of the patients were recorded and collected. The characteristic ROC curve was applied to further assess the predictive value of the ACCI for POD in patients following OPCABG surgery. Results A total of 89 patients were enrolled, including 45 patients in the low-ACCI group and 44 patients in the high-ACCI group. The incidence of POD was higher in the high-ACCI group than in the low-ACCI group (45.5% vs. 15.6%, P = 0.003). Multivariate logistic regression analyses showed that the ACCI (OR, 2.433; 95% CI, 1.468-4.032; P = 0.001) was an independent risk factor for POD. The ACCI accurately predicted POD in patients following OPCABG surgery with an AUC of 0.738, and the Hosmer-Lemeshow goodness of fit test yielded X2 = 5.391 (P = 0.145). Conclusion The high-ACCI group showed a high incidence of POD. The ACCI was an independent factor associated with POD in patients following OPCABG surgery. In addition, the ACCI could accurately predict POD in patients following OPCABG surgery. Clinical Trial Registration ClinicalTrials.gov, identifier CHiCTR2100052811.
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Affiliation(s)
- Ying Ma
- Department of Geriatric Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Dongxin Sui
- Department of Respiration, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Shaozhong Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaomei Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Joseph Oldam
- B.S. Neuroscience, Center for Research on Cardiac Intermediate Filaments, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jessica L. Semel
- Centerfor Research on Cardiac Intermediate Filaments, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zhihao Wang
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Ningning Fang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Laraia KN, Pepe RJ, Sabatino ME, Dewan KC, Yoo J, Yang NK, Chao JC, Takebe M, Sunagawa G, Ikegami H, Lemaire A, Russo MJ, Lee LY. Ambulatory Electrocardiography Monitoring for Early Discharge After Minimally Invasive Valve Surgery. J Surg Res 2023; 292:182-189. [PMID: 37633247 DOI: 10.1016/j.jss.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION We sought to compare outcomes after early discharge in patients with and without predischarge diagnosis of arrhythmia following minimally invasive valve surgery (MIVS). MATERIALS AND METHODS We retrospectively reviewed ambulatory electrocardiography (AECG) datasheets and medical records of patients discharged with 14-d AECG monitoring from our facility between October 2019 and March 2022 ≤ 3 d after MIVS. Baseline and clinical characteristics, arrhythmias during AECG monitoring, and 30-d adverse outcomes were reported for the population and stratified by presence or absence of predischarge arrhythmia. RESULTS Of 41 patients discharged ≤3 d postoperatively of MIVS, 17 (41.5%) experienced predischarge arrhythmias and 24 (58.5%) did not. The population was predominantly male and White with a median age of 62 y [57, 70]. Baseline and clinical characteristics did not differ between subgroups. Most patients (92.7% [n = 38]) experienced one or more tachyarrhythmias during the AECG monitoring period. There were similar proportions of patients experiencing atrial fibrillation in both groups, but patients with predischarge arrhythmias had higher burden of atrial fibrillation on AECG monitoring (27.60% [6.57%, 100%] versus 1.65% [0.76%, 4.32%]; P = 0.004). The predischarge arrhythmia subgroup had higher proportions of patients experiencing nonsustained ventricular tachycardia but lower proportions experiencing supraventricular tachycardia. There were no mortalities within 30 d of surgery. Six (14.6%) patients were readmitted within 30 d with equal proportions of readmissions between subgroups (P = 0.662). CONCLUSIONS Early discharge timelines and noninvasive monitoring techniques can allow patients to return to their normal activities quicker in the comfort of their own home with no increased risk of morbidity or mortality.
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Affiliation(s)
- Kayla N Laraia
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Russell J Pepe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Marlena E Sabatino
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Krish C Dewan
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jin Yoo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - NaYoung K Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joshua C Chao
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Manabu Takebe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Gengo Sunagawa
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Hirohisa Ikegami
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Mark J Russo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Leonard Y Lee
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
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Lobdell KW, Crotwell S, Frederick J, Watts LT, LeNoir B, Skipper ER, Maxey T, Russell GB, Habib R, Rose GA. Technologic Transformation of Perioperative Cardiac Care and Outcomes. Ann Thorac Surg 2023; 116:413-419. [PMID: 37004803 DOI: 10.1016/j.athoracsur.2023.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND The "Perfect Care" initiative engages, educates, and enrolls adult cardiac surgery patients into a comprehensive program that incorporates remote perioperative monitoring (RPM). This study investigated the impact of RPM on postoperative length of stay, 30-day readmission and mortality, and other outcomes. METHODS This quality improvement project compared outcomes in 354 consecutive patients who underwent isolated coronary artery bypass and who were enrolled in RPM between July 2019 and March 2022 at 2 centers against outcomes in propensity-matched control patients from a pool of 1301 patients who underwent isolated coronary artery bypass from April 2018 to March 2022 without RPM. Data were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database, and outcomes were analyzed according to its definitions. RPM used perioperative standard practice routines, a digital health kit for remote monitoring, a smartphone application and platform, and nurse navigators. Propensity scores were generated with RPM as the outcome measure, and a 2:1 match was generated using a nearest-neighbor matching algorithm. RESULTS Patients who underwent isolated coronary artery bypass and who were participating in RPM showed a statistically significant, 15.4% (1 day) reduction in postoperative length of stay (P < .0001) and a 44% reduction in 30-day readmission and mortality (P < .039) compared with matched control patients. Significantly more RPM participants were discharged directly home instead of to a facility (99.4% vs 92.0%; P < .0001). CONCLUSIONS The RPM platform and associated efforts to engage and monitor adult cardiac surgery patients remotely is feasible, is embraced by patients and clinicians, and transforms perioperative cardiac care by significantly improving outcomes and reducing variation.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina.
| | - Shannon Crotwell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - John Frederick
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Larry T Watts
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Bradley LeNoir
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Eric R Skipper
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Thomas Maxey
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Gregory B Russell
- Clinical & Translational Science Institute, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Geoffrey A Rose
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
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11
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Obafemi T, Mullis D, Bajaj S, Krishna P, Boyd J. Results following implementation of a cardiac surgery ERAS protocol. PLoS One 2023; 18:e0277868. [PMID: 37450443 PMCID: PMC10348550 DOI: 10.1371/journal.pone.0277868] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/04/2022] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Adequate peri-operative care is essential to ensuring a satisfactory outcome in cardiac surgery. In this study, we look at the impact of evidence-based protocols implemented at Stanford Hospital. METHODS This study is a single-center, retrospective analysis. Enhanced recovery after surgery (ERAS) protocols were implemented for CABG/Valve and open Aortic operations on 11/1/2017 and 6/1/2018, respectively. Propensity-score matched analysis was used to compare 30-day mortality and morbidity of patients from the pre- and post-implementation cohorts. Secondary endpoints included the following: total hospital length of stay (LOS), ICU LOS, time until extubation, and time until urinary catheter removal. RESULTS After the implementation of the ERAS protocols for CABG/Valve operations, the median post-op LOS decreased from 7.0 days to 6.1 days (p<0.001), and median ICU LOS decreased from 69.9 hours to 54.0 (p = 0.098). There was no significant decrease in 30-day mortality (4% to 3.3%, p = 0.47). However, the incidence of post-op ventilator associated pneumonia (VAP) decreased from 5.0% to 2.1% (p = 0.003) and post-op urinary tract infections (UTIs) from 8.3% to 3.6% (p<0.001). Patients who underwent open aortic procedures experienced an improvement in 30-day mortality (7% to 3.5%, p = 0.012), decrease in median ICU LOS (91.7 hours to 69.6 hours, p<0.001), and a decrease in duration of mechanical ventilation (79.3 hours to 46.3 hours, p = 0.003). There was a decrease in post-op LOS, post-op VAP, and post-op UTI, although statistical significance was not attained. CONCLUSION At Stanford Hospital, ERAS pathways have led to decreased morbidity and LOS while simultaneously improving mortality amongst our critically ill patient population.
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Affiliation(s)
- Tomi Obafemi
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States of America
| | - Danielle Mullis
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States of America
| | - Simar Bajaj
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States of America
| | - Purnima Krishna
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States of America
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States of America
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12
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Pollock KM, Ambroziak R, Mullen C, King L, Barsa A. Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00234-3. [PMID: 37127522 DOI: 10.1053/j.jvca.2023.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/17/2023] [Accepted: 03/30/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation. DESIGN Single-center, retrospective cohort study. SETTING Cleveland Clinic Akron General Hospital. PARTICIPANTS Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital. INTERVENTIONS A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management. MEASUREMENTS AND MAIN RESULTS The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005). CONCLUSIONS Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.
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Affiliation(s)
- Kailee M Pollock
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Ronda Ambroziak
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Chanda Mullen
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Liz King
- Department of Surgery, Cleveland Clinic Akron General, Akron, OH
| | - Angela Barsa
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH.
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13
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Martindale RG. Novel nutrition strategies to enhance recovery after surgery. JPEN J Parenter Enteral Nutr 2023; 47:476-481. [PMID: 36938940 DOI: 10.1002/jpen.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 01/20/2023] [Accepted: 02/08/2023] [Indexed: 03/21/2023]
Abstract
Surgery and traumatic injury set off a cascade of metabolic changes that are becoming better understood. Recently, strategies and protocols have been developed for optimizing outcomes, and this has yielded beneficial results. This brief review evaluates three specific nutrition or metabolic interventions in the postoperative setting that attempt to optimize outcomes. We limited this to three subspecialty areas including oncologic surgery, orthopedic surgery, and cardiac surgery. These agents included fish oils, factors to prevent dysbiosis, and resistance exercise and its role in enhancing protein update. Where these novel agents fit into the basic tenets of postoperative nutrition interventions does not change the narrative: deliver graduated early enteral feeding to attenuate the metabolic response to surgical stress, maintain the gastrointestinal mucosal barrier, use immune/metabolic modulation to enhance immune response while attenuating excessive inflammation, and support the microbiome.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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14
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Yuan W, Huang G, Dai P, Zhong Y, Ai Q, Liao Q. Application of enhanced recovery after surgery in perioperative patients undergoing laparoscopic surgery for gastric cancer: A meta-analysis. Medicine (Baltimore) 2023; 102:e32962. [PMID: 36930125 PMCID: PMC10019270 DOI: 10.1097/md.0000000000032962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/24/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND To analyze the effect of enhanced recovery after surgery (ERAS) in perioperative patients undergoing laparoscopic surgery for gastric cancer (GC). METHODS We searched the literature databases of PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://www.webofscience.com/) for studies related to ERAS and laparoscopic surgery for GC from their inception till October 2022, and the retrieved articles were further screened for analysis. The literature quality was evaluated based on the Cochrane risk of bias tool. The endpoints included the first postoperative exhaust time, first postoperative bowel movement, length of stay, complications and hospitalization expenses. The meta-analysis was performed using RevMan 5.4 software. RESULTS 11 studies were included, involving 2039 patients. Meta-analysis showed that the first postoperative exhaust and bowel movement were earlier and the length of stay was shorter in the experimental group (e.g.,) than in the control group (CG) (P < .05). Moreover, a lower incidence of complications and markedly reduced hospitalization expenses were determined in for example (P < .05). Due to the heterogeneity in the comparison of indicators such as the first postoperative exhaust and bowel movement across articles, a funnel plot was drawn for observations. The plot was found to be basically symmetrical, indicating small results bias and reliable reference significance of our findings. CONCLUSION ERAS for perioperative patients undergoing laparoscopic surgery for GC can effectively shorten the postoperative rehabilitation cycle of patients, improve surgical safety and reduce treatment costs.
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Affiliation(s)
- Wei Yuan
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Guigui Huang
- Department of Infection, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Peng Dai
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - You Zhong
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Qiubao Ai
- Department of The Third General Surgery, Xinyu People’s Hospital, Xinyu, Jiangxi Province, China
| | - Qinghui Liao
- Department of Nursing, Maternity and Child Health Hospital of Xinyu, Xinyu, Jiangxi Province, China
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15
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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16
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Edwards J, Binongo J, Mullin B, Wei J, Ghelani K, Kumarasamy M, Hanson P, Duggan M, Shoffstall J, Halkos M. Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:511-517. [PMID: 35870521 DOI: 10.1016/j.athoracsur.2022.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/16/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated. METHODS A total of 215 consecutive patients underwent robotic-assisted coronary artery bypass grafting, with 156 preoperatively stratified into conventional ICU recovery vs 59 candidates for a defined ICU-bypass protocol involving recovery room and floor care. Of these, 40 candidates completed the protocol, and 19 had conversion-to-ICU recovery. Because of right-skewed distribution, inpatient cost was log-transformed, and linear regression models were constructed to estimate geometric mean ratios (GMRs) comparing inpatient cost for these groups (conventional ICU recovery, ICU-bypass, conversion-to-ICU recovery), adjusted for The Society of Thoracic Surgeons Predicted Risk of Mortality score. RESULTS Compared with the conventional ICU group, the ICU-bypass group conferred a 15% reduction in total inpatient (GMR, 0.85; P = .0007) and a 14% reduction in total variable direct costs (GMR, 0.86; P = .003). Compared with the conventional ICU group, the ICU-bypass and conversion-to-ICU groups had similar net hospital stay reductions (1.6-1.7 days). Relative to the conventional ICU group, ICU and floor duration were shortened after conversion to ICU, with a trend to reduced costs. Cardiac arrest, 30-day mortality, and stroke were absent, and other key adverse events did not differ between groups. CONCLUSIONS A selective, successful ultra-fast-track ICU-bypass protocol for robotic-assisted coronary artery bypass grafting reduces inpatient cost without affecting short-term outcomes. Conversion-to-ICU recovery also maintains outcomes and trends toward reduced costs.
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Affiliation(s)
- Joseph Edwards
- Department of Anesthesiology, Emory University, Atlanta, Georgia.
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brian Mullin
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Jane Wei
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kunali Ghelani
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Peyton Hanson
- School of Medicine, Emory University, Atlanta, Georgia
| | - Michael Duggan
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | - Michael Halkos
- Department of Surgery, Emory University, Atlanta, Georgia
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17
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Lim MH, Lee CH, Ju MH, Je HG. Impact of Sarcopenia on Outcomes of Minimally Invasive Cardiac Surgery. Semin Thorac Cardiovasc Surg 2023; 35:77-85. [PMID: 34780924 DOI: 10.1053/j.semtcvs.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 01/11/2023]
Abstract
Sarcopenia is an objective marker of poor outcome following cardiac surgery through median sternotomy. However, the clinical impact of sarcopenia after minimally invasive cardiac surgery (MICS) has not been well established. This study aimed to analyze the influence of sarcopenia on the early and late outcomes following MICS. We retrospectively examined 1248 patients who underwent MICS via right mini-thoracotomy or upper sternotomy between February 2009 and April 2020. Patients older than 65 years who underwent preoperative computed tomography were enrolled. Sarcopenia was defined as the lowest sex-specific quartile of the body surface area adjusted psoas muscle area. The early operative and late survival outcomes were compared, and the predictor of late composite outcome was analyzed using Cox proportional regression model. Early and late composite outcomes in both groups were also compared. A total of 367 patients were classified into the sarcopenia (n = 92) or non-sarcopenia (n = 275) group. Patients in the sarcopenia group were older, and had lower preoperative hemoglobin and albumin levels. They had higher estimated surgical mortality, but similar early mortality and major morbidity. The survival and late composite outcome were comparable between the two groups. Sarcopenia was neither an independent predictor of late death nor a composite outcome in the multivariable model. After MICS, patients with sarcopenia displayed comparable perioperative outcomes and survival. The clinical impact of sarcopenia on postoperative outcomes might be alleviated by MICS and early recovery protocol after MICS. MICS could be a reasonable approach for elderly patients with sarcopenia.
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Affiliation(s)
- Mi Hee Lim
- Cardiovascular Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Korea
| | - Chee-Hoon Lee
- Cardiovascular Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Korea
| | - Min Ho Ju
- Cardiovascular Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Korea
| | - Hyung Gon Je
- Cardiovascular Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Korea.
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18
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Brown CH, Yanek L, Healy R, Tsay T, Di J, Goeddel L, Young D, Zipunnikov V, Schrack J. Comparing three wearable accelerometers to measure early activity after cardiac surgery. JTCVS OPEN 2022; 11:176-191. [PMID: 36172447 PMCID: PMC9510817 DOI: 10.1016/j.xjon.2022.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/30/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
Objective Wearable activity monitors can provide detailed data on activity after cardiac surgery and discriminate a patient's risk for hospital-based outcomes. However, comparative data for different monitoring approaches, as well as predictive ability over clinical characteristics, are lacking. In addition, data on specific thresholds of activity are needed. The objective of this study was to compare 3 wearable activity monitors and 1 observational mobility scale in discriminating risk for 3 hospital-based outcomes, and to establish clinically relevant step thresholds. Methods Cardiac surgery patients were enrolled between June 2016 and August 2017 in a cohort study. Postoperative activity was measured by 3 accelerometry monitors (StepWatch Ambulation Monitor, Fitbit Charge HR, and ActiGraph GT9X) and 1 nurse-based observation scale. Monitors represent a spectrum of characteristics, including wear location (ankle/wrist), output (activity counts/steps), consumer accessibility, and cost. Primary outcomes were duration of hospitalization >7 days, discharge to a nonhome location, and 30-day readmission. Results Data were available from 193 patients (median age 67 years [interquartile range, 58-72]). All postoperative day 2 activity metrics (ie, from StepWatch, Fitbit, ActiGraph, and the observation scale) were independently associated with prolonged hospitalization and discharge to a nonhome location. Only steps as measured by StepWatch was independently associated with 30-day readmission. Overall, StepWatch provided the greatest discrimination (C-statistics 0.71-0.76 for all outcomes). Step thresholds between 250 and 500 steps/day identified between 74% and 96% of patients with any primary outcome. Conclusions Data from wearable accelerometers provide additive value in early postoperative risk-stratification for hospital-based outcomes. These results both support and provide guidance for activity-monitoring programs after cardiac surgery.
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Affiliation(s)
- Charles H. Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
- Address for reprints: Charles H. Brown, IV, MD, MHS, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21210.
| | - Lisa Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ryan Healy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Tiffany Tsay
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Junrui Di
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Lee Goeddel
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Daniel Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nev
| | - Vadim Zipunnikov
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Jennifer Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - the Cardiac Surgery Mobility Working GroupWhitmanGlennMDaMandalKaushikMDaMadeiraTimCRNPaGrantMichael C.MD, MSEbHoyerErik H.MDcDepartment of Surgery, Johns Hopkins University School of Medicine, Baltimore, MdDepartment of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MdDepartment of Physical Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
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19
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Dave MG, Chudyk AM, Oravec N, Kent DE, Duhamel TA, Schultz AS, Arora RC. Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations. JTCVS OPEN 2022; 12:306-314. [PMID: 36590723 PMCID: PMC9801247 DOI: 10.1016/j.xjon.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 01/04/2023]
Abstract
Objective In 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective. Methods Using a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities. Results Seven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively. Conclusions Exploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.
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Affiliation(s)
- Mudra G. Dave
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada,Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Anna M. Chudyk
- St Boniface Research Centre, Health Services & Structural Determinants of Health Research, Winnipeg, Manitoba, Canada,College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nebojša Oravec
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David E. Kent
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada,Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Todd A. Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada,Institute of Cardiovascular Sciences, Alberchtsen Research Centre, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Annette S.H. Schultz
- St Boniface Research Centre, Health Services & Structural Determinants of Health Research, Winnipeg, Manitoba, Canada,College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C. Arora
- Cardiac Sciences Manitoba, St Boniface Hospital, Winnipeg, Manitoba, Canada,Institute of Cardiovascular Sciences, Alberchtsen Research Centre, St Boniface Hospital, Winnipeg, Manitoba, Canada,Section of Cardiac Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada,Address for reprints: Rakesh C. Arora, MD, PhD, IH Asper Clinical Research Institute, St Boniface Hospital, CR3015–369 Taché Ave, Winnipeg, MB, Canada R2H 2A6.
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20
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Sabatino ME, Okoh AK, Chao JC, Soto C, Baxi J, Salgueiro LA, Olds A, Ikegami H, Lemaire A, Russo MJ, Lee LY. Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery. Ann Thorac Surg 2022; 114:91-97. [PMID: 34419437 PMCID: PMC10893855 DOI: 10.1016/j.athoracsur.2021.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/07/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort. CONCLUSIONS In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.
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Affiliation(s)
- Marlena E Sabatino
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alexis K Okoh
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Joshua C Chao
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Cassandra Soto
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jigesh Baxi
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Lauren A Salgueiro
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Olds
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hirohisa Ikegami
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Anthony Lemaire
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Mark J Russo
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
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21
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Klotz SGR, Ketels G, Behrendt CA, König HH, Kohlmann S, Löwe B, Petersen J, Stock S, Vettorazzi E, Zapf A, Zastrow I, Zöllner C, Reichenspurner H, Girdauskas E. Interdisciplinary and cross-sectoral perioperative care model in cardiac surgery: implementation in the setting of minimally invasive heart valve surgery (INCREASE)-study protocol for a randomized controlled trial. Trials 2022; 23:528. [PMID: 35739541 PMCID: PMC9229105 DOI: 10.1186/s13063-022-06455-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Valvular heart diseases are frequent and increasing in prevalence. Minimally invasive heart valve surgery embedded in an interdisciplinary enhanced recovery after surgery (ERAS) program may have potential benefits with regard to reduced length of stay and improved patient reported outcomes. However, no prospective randomized data exist regarding the superiority of ERAS program for the patients’ outcome. Methods We aim to randomize (1:1) a total of 186 eligible patients with minimally invasive heart valve surgery to an ERAS program vs. standard treatment at two centers including the University Medical Center Hamburg-Eppendorf, Germany, and the University Hospital Augsburg, Germany. The intervention is composed out of pre-, peri-, and postoperative components. The preoperative protocol aims at better preparation for the operation with regard to physical activity, nutrition, and psychological preparedness. Intraoperative anesthesiologic and surgical management are trimmed to enable an early extubation. Patients will be transferred to a specialized postoperative anesthesia care unit, where first mobilization occurs 3 h after surgery. Transfer to low care ward will be at the next day and discharge at the fifth day. Participants in the control group will receive treatment as usual. Primary endpoints include functional discharge at discharge and duration of in-hospital care during the first 12 months after index surgery. Secondary outcomes include health-related quality of life, health literacy, and level of physical activity. Discussion This is the first randomized controlled trial evaluating the effectiveness of an ERAS process after minimally invasive heart valve surgery. Interprofessional approach is the key factor of the ERAS process and includes in particular surgical, anesthesiological, physiotherapeutic, advanced nursing, and psychosocial components. A clinical implication guideline will be developed facilitating the adoption of ERAS model in other heart teams. Trial registration The study has been registered in ClinicalTrials.gov (NCT04977362 assigned July 27, 2021).
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Affiliation(s)
- Susanne G R Klotz
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gesche Ketels
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian A Behrendt
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Sebastian Kohlmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Sina Stock
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Inke Zastrow
- Department of Patient and Care Management, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
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22
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Effects of a spray-based oropharyngeal moisturising programme for patients following endotracheal extubation after cardiac surgery: A randomised, controlled three-arm trial. Int J Nurs Stud 2022; 130:104214. [DOI: 10.1016/j.ijnurstu.2022.104214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 01/18/2023]
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23
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Shih E, DiMaio JM, Squiers JJ, Wheeless J, Hoffman WJ, Banwait JK, Hamandi M, Baxter R, Harrington KB. Effect of Pre-Incisional Liposomal Bupivacaine Sternal Blockade on Post-Sternotomy Opioid Use. Ann Thorac Surg 2022; 114:1562-1567. [DOI: 10.1016/j.athoracsur.2022.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/23/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
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24
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Oravec N, Arora RC, Bjorklund B, Gregora A, Monnin C, Dave MG, Duhamel TA, Kent DE, Schultz ASH, Chudyk AM. Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01675-5. [PMID: 34924192 DOI: 10.1016/j.jtcvs.2021.11.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE(S) In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact. METHODS Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes. RESULTS Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop. CONCLUSIONS Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.
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Affiliation(s)
- Nebojša Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Brian Bjorklund
- Enhanced Recovery Protocols for Cardiac Surgery Patient Researcher Group, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - April Gregora
- Enhanced Recovery Protocols for Cardiac Surgery Patient Researcher Group, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Caroline Monnin
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mudra G Dave
- Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada; Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd A Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada; Institute of Cardiovascular Sciences, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - David E Kent
- Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Annette S H Schultz
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada; Health Services & Structural Determinants of Health Research Group, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Anna M Chudyk
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada; Health Services & Structural Determinants of Health Research Group, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
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25
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He L, Li Y, Liao X, Wang Y, Pu L, Gao F, Wang G. Effects of evidence-based nursing combined with enhanced recovery after surgery on shoulder joint function and neurological function after arthroscopic rotator cuff injury repair. Medicine (Baltimore) 2021; 100:e27951. [PMID: 34964778 PMCID: PMC8615422 DOI: 10.1097/md.0000000000027951] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/02/2021] [Indexed: 01/05/2023] Open
Abstract
To explore the effect of Enhanced Recovery After Surgery (ERAS) nursing combined with limbs training on shoulder joint range of motion and neurological function of patients with rotator cuff injury after surgery.60 patients who underwent arthroscopic rotator cuff repair were randomly divided into experimental group and control group, with 30 cases in each group. The experimental group received ERAS nursing combined with rehabilitation training, while the control group received routine nursing. The prognostic effects of nursing care and shoulder joint range of motion between the two groups were compared.There were differences in general indicators between the two groups (P = .001). There was no significant difference in the evaluation indexes of the two groups of patients (P > .05). The visual analog scale score and the degree of swelling of the affected limb of the experimental group were lower than those of the control group (P = .001; .001). After 1, 6, 12 weeks of treatment, the Constant-Murley, American Shoulder and Elbow Surgeons and University of California-Los Angeles scores of the experimental group were higher than those of the control group (P = .001; .001; .001). After 2, 4 weeks of treatment, the National Institutes of Health Stroke Scale scores of the experimental group were lower than those of the control group (P = .001). The self-efficacy evaluation of the experimental group was significantly better than that of the control group (P = .001); the complication rate was lower than that of the control group (P = .006).Compared with simple postoperative nursing recovery, ERAS nursing combined with limbs training can improve the exercise capacity of the shoulder joint and the recovery of neurological function, reduce the occurrence of complications.
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26
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Vaughan BN, Bartone CL, McCarthy CM, Answini GA, Hurford WE. Ultrasound-Guided Continuous Bilateral Erector Spinae Plane Blocks Are Associated with Reduced Opioid Consumption and Length of Stay for Open Cardiac Surgery: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10215022. [PMID: 34768541 PMCID: PMC8584924 DOI: 10.3390/jcm10215022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
This study tested the hypothesis that continuous bilateral erector spinae plane blocks placed preoperatively would reduce opioid consumption and improve outcomes compared with standard practice in open cardiac surgery patients. Patients who received bilateral continuous erector spinae plane blocks for primary open coronary bypass, aortic valve, or ascending aortic surgery were compared to a historical control group. Patients in the block group received a 0.5% ropivacaine bolus preoperatively followed by a 0.2% ropivacaine infusion begun postoperatively. No other changes were made to the perioperative care protocol. The primary outcome was opioid consumption. Secondary outcomes were time to extubation and length of stay. Twenty-eight patients received continuous erector spinae plane blocks and fifty patients served as historic controls. Patients who received blocks consumed less opioids, expressed as oral morphine equivalents, both intraoperatively (34 ± 17 vs. 224 ± 125 mg) and during their hospitalization (224 ± 108 vs. 461 ± 185 mg). Patients who received blocks had shorter times to extubation (126 ± 87 vs. 257 ± 188 min) and lengths of stay in the intensive care unit (35 ± 17 vs. 58 ± 42 h) and hospital (5.6 ± 1.6 vs. 7.7 ± 4.6 days). Continuous erector spinae plane blocks placed prior to open cardiac surgical procedures reduced opioid consumption, time to extubation, and length of stay compared to a standard perioperative pathway.
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Affiliation(s)
- Brian N. Vaughan
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45267, USA;
- Correspondence: ; Tel.: +1-513-258-6313
| | - Cheryl L. Bartone
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - Catherine M. McCarthy
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - Geoffrey A. Answini
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - William E. Hurford
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45267, USA;
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27
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Damstra J, Geerts BF, Rex S, Vlaar APJ, Driessen AHG, Engelman DT, Klautz RJM, Eberl S. Perioperative Care Standards in Cardiac Surgery Patients Aiming at Enhancing Recovery: A Nationwide Survey in the Netherlands and Belgium. J Cardiothorac Vasc Anesth 2021; 36:109-117. [PMID: 34602324 DOI: 10.1053/j.jvca.2021.08.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this survey was to describe existing perioperative care standards and best practices in the Netherlands and Belgium. DESIGN An online survey was followed up by an in-depth personal interview. The main outcomes were the existing standards of perioperative care for patients undergoing cardiac surgery. SETTING The online survey and subsequent interviews were targeted to one representative in the intensive care unit (ICU), cardiac surgery, and anesthesiology department from each cardiac surgical center in the Netherlands and Belgium. PARTICIPANTS A representative intensive care physician, cardiac surgeon, and cardiac anesthesiologist. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The response rate was 60% (71% for the Netherlands, and 44% in Belgium). Agreement across centers was found for discontinuation of proton-pump inhibitors (80%) and avoiding intra- and postoperative (92%) nonsteroidal antiinflammatory drugs. Additionally, 98% of respondents stated that physiotherapy should be started immediately in the ICU. Major divergence was found for elements such as the discontinuation of angiotensin-converting enzyme inhibitors (55%) or the postoperative use of chest support vests (44%). CONCLUSIONS The authors demonstrated a wide range of different local protocols. Strategies differed among disciplines, hospitals, and countries. This emphasized the need for the implementation of a more universal protocol to further reduce variance and improve recovery practices. This nationwide survey was the first of its kind simultaneously studying best practices for cardiac surgery through the entire care pathway at the advent of Enhanced Recovery After Surgery (ERAS) Cardiac implementation. A multinational randomized controlled trial to test the implementation of an evidence-based ERAS Cardiac protocol is the next step to pave the way for further outcome improvements in this high-risk population.
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Affiliation(s)
- Jill Damstra
- Department of Anesthesiology, Amsterdam University Medical Center (UMC), Location AMC, the Netherlands.
| | - Bart F Geerts
- Department for Intensive Care, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Steffen Rex
- Department of Anesthesiology, University Hospital Leuven, Belgium; and Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Belgium
| | | | - Antoine H G Driessen
- Department of Cardiothoracic Surgery, Amsterdam UMC, location AMC, the Netherlands
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, Springfield and University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Amsterdam UMC, location AMC, the Netherlands
| | - Susanne Eberl
- Department of Anesthesiology, Amsterdam University Medical Center (UMC), Location AMC, the Netherlands
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28
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Clendenen N, Ahlgren B, Robitaille MJ, Christensen E, Morabito J, Grae L, Lyman M, Weitzel N. Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology. Semin Cardiothorac Vasc Anesth 2021; 25:94-106. [PMID: 33938302 PMCID: PMC10088871 DOI: 10.1177/10892532211013614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.
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Affiliation(s)
| | - Bryan Ahlgren
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark J Robitaille
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Joseph Morabito
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lyndsey Grae
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Lyman
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathaen Weitzel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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29
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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30
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Rotar EP, Beller JP, Smolkin ME, Chancellor WZ, Ailawadi G, Yarboro LT, Hulse M, Ratcliffe SJ, Teman NR. Prediction of Prolonged Intensive Care Unit Length of Stay Following Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 34:172-179. [PMID: 33689923 DOI: 10.1053/j.semtcvs.2021.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
Intensive care unit (ICU) costs comprise a significant proportion of the total inpatient charges for cardiac surgery. No reliable method for predicting intensive care unit length of stay following cardiac surgery exists, making appropriate staffing and resource allocation challenging. We sought to develop a predictive model to anticipate prolonged ICU length of stay (LOS). All patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery with a Society of Thoracic Surgeons (STS) predicted risk score were evaluated from an institutional STS database. Models were developed using 2014-2017 data; validation used 2018-2019 data. Prolonged ICU LOS was defined as requiring ICU care for at least three days postoperatively. Predictive models were created using lasso regression and relative utility compared. A total of 3283 patients were included with 1669 (50.8%) undergoing isolated CABG. Overall, 32% of patients had prolonged ICU LOS. Patients with comorbid conditions including severe COPD (53% vs 29%, P < 0.001), recent pneumonia (46% vs 31%, P < 0.001), dialysis-dependent renal failure (57% vs 31%, P < 0.001) or reoperative status (41% vs 31%, P < 0.001) were more likely to experience prolonged ICU stays. A prediction model utilizing preoperative and intraoperative variables correctly predicted prolonged ICU stay 76% of the time. A preoperative variable-only model exhibited 74% prediction accuracy. Excellent prediction of prolonged ICU stay can be achieved using STS data. Moreover, there is limited loss of predictive ability when restricting models to preoperative variables. This novel model can be applied to aid patient counseling, resource allocation, and staff utilization.
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Affiliation(s)
- Evan P Rotar
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark E Smolkin
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mathew Hulse
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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Ikonomidis JS. Commentary: Outcomes of 3-day discharge after elective cardiac surgery. J Card Surg 2021; 36:1448-1449. [PMID: 33567108 DOI: 10.1111/jocs.15403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- John S Ikonomidis
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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Malik K, Poletto G, Musto L, Giustiniano E, Cecconi M, Civilini E. Implementation of a perioperative protocol to enhance open aortic repair. J Vasc Surg 2021; 74:434-441.e2. [PMID: 33548439 DOI: 10.1016/j.jvs.2020.12.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/15/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although appreciated for its long-term benefits, open repair of abdominal aortic aneurysms (AAA) is associated with a significant perioperative burden. Enhanced recovery and fast track protocols have improved surgical outcomes in many specialties, but remain scarcely applied in the vascular field. METHODS Based on the applied perioperative protocol in a single-center experience, three consecutive study groups were identified among 394 consecutive patients undergoing elective AAA open repair in the last 12 years. Group A included 66 patients who underwent traditional surgery, group B comprised 225 patients treated according to a partially adopted perioperative protocol, and group C consisted of 103 patients, operated in line with a complete perioperative protocol. The aim of this study was to evaluate the impact of the perioperative protocol on recovery time by measuring complication rates, analgesic and antiemetic control, and return of bowel function and ambulation, as well as the length of hospitalization. RESULTS The study groups had similar baseline characteristics. A significant improvement was noted in the complication rates (P = .019) and hospitalization time (P < .001) following a complete implementation of the perioperative protocol, where the median hospitalization time was 3 days. No mortality and no readmissions within 30 postoperative days were recorded in this group. There was an improvement in pain levels, as well as postoperative nausea and vomiting control (P < .001). CONCLUSIONS Perioperative protocol implementation in AAA open repair is feasible; the clinical outcomes may be improved when strictly adhering to the protocol. All the applied perioperative management interventions seem to have a synergic effect on shortening the recovery time.
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Affiliation(s)
- Karolina Malik
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Poletto
- Vascular Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Liam Musto
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Giustiniano
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Efrem Civilini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Vascular Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
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Szerlip M, Tabachnick D, Hamandi M, Caras L, Lanfear AT, Squiers JJ, Harrington K, Potluri SP, DiMaio JM, Wooley J, Pollock B, Schaffer JM, Brinkman WT, Brown DL, Mack MJ. Safe implementation of enhanced recovery after surgery protocol in transfemoral transcatheter aortic valve replacement. Proc (Bayl Univ Med Cent) 2020; 34:5-10. [PMID: 33456136 DOI: 10.1080/08998280.2020.1810198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are gaining wide acceptance. We evaluated ERAS protocol implementation in transfemoral transcatheter aortic valve replacement (TAVR) patients. The ERAS protocol included (1) moderate sedation or general anesthesia with on-table extubation, (2) no pulmonary artery or urinary catheters, (3) arterial line removal within 4 hours, (4) no postoperative narcotics, (5) mobilization at 4 hours and ambulation within 8 hours, and (6) antihypertensive reinstitution without nodal blockers. Patients who received TAVR before and after ERAS implementation were compared (N = 121 and N = 368, respectively). The primary endpoint was total hospital length of stay (LOS). ERAS patients had a lower mean Society of Thoracic Surgeons predicted risk of mortality (6.7% vs 7.5%; P = 0.04). Unadjusted analysis demonstrated that ERAS was associated with significantly decreased mean LOS (2.8 vs 4.0 days, P < 0.001), decreased 30-day mortality (0.8% vs 5.0%; P = 0.003), and increased discharge home (90.2% vs 79.3%, P = 0.002) with no increase in 30-day readmission (11.1% vs 14.0%, P = 0.39). After risk adjustment, ERAS patients had a 1.87-day shorter LOS (P = 0.001) and trended toward increased discharge home (odds ratio 1.76, P = 0.078) without increased readmission (odds ratio 0.74, P = 0.4). An ERAS protocol for TAVR is safe and is associated with shorter LOS without increased readmission.
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Affiliation(s)
- Molly Szerlip
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Deborah Tabachnick
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Mohanad Hamandi
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - LuAnn Caras
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Allison T Lanfear
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - John J Squiers
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas.,General Surgery Department, Baylor University Medical Center, Dallas, Texas
| | - Katherine Harrington
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Srinivasa P Potluri
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - J Michael DiMaio
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Jordan Wooley
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | | | - Justin M Schaffer
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - William T Brinkman
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - David L Brown
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Michael J Mack
- Cardiovascular Research Department, Baylor Scott and White The Heart Hospital, Plano, Texas
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Affiliation(s)
- Aaron Bettenhausen
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, Ste 211L, San Antonio, TX 78229
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, Ste 211L, San Antonio, TX 78229.
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