Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: Retrospective analysis of patient outcomes

Enhanced recovery after surgery program for patients undergoing isolated elective coronary artery bypass surgery improves postoperative outcomes

OBJECTIVE

To evaluate the effect of a perioperative systematic standardized enhanced recovery after surgery (ERAS) program for patients undergoing isolated elective coronary artery bypass grafting (CABG) in terms of mortality, hospital morbidities, and length of stay.

METHODS

From January 2015 to September 2020, 1101 patients underwent isolated elective CABG. Our standardized systematic ERAS program was implemented in November 2018. Propensity score matching resulted in well-matched pairs of 362 patients receiving standard perioperative care (control group) and 362 patients on the ERAS program (ERAS group). There were no significant intergroup differences in preoperative and operative data except for the normothermia rate, which was significantly greater in the ERAS group (P < .001). The primary outcome was 3-year mortality. The secondary outcomes were hospital morbidities and length of stay.

RESULTS

In-hospital and 3-year mortality did not differ between the 2 groups. The ERAS program was associated with a significant relative risk decrease in mechanical ventilation duration (-53.1%, P = .003), length of intensive care unit stay (-28.0%, P = .015), length of hospital stay (-10.5%, P = .046), bronchopneumonia (-51.5%, P < .001), acute respiratory distress syndrome (-50.8%, P = .050), postoperative delirium (-65.4%, P = .011), moderate-to-severe acute kidney injury (-72.0%, P = .009), 24-hour chest tube output (-26.4%, P < .001), and overall red blood cell transfusion rate (-32.4%, P = .005) compared with the control group.

CONCLUSIONS

A systematic standardized ERAS program for low-risk patients undergoing isolated elective CABG was associated with a significant improvement in postoperative outcomes, reduction in red blood cell transfusion, shorter lengths of intensive care unit and hospital stays, and comparable long-term mortality.

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BACKGROUND

An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.

METHODS

This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.

RESULTS

We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.

CONCLUSION

Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.

TRIALS REGISTRATION

The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

OBJECTIVES

Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy.

METHODS

We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4.

RESULTS

Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001).

CONCLUSIONS

Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Effect of a preoperative evidence-based care education on postoperative recovery of cardiac surgery patients: A quasi-experimental study

INTRODUCTION

Preoperative nursing care affects many factors such as reducing the length of hospital stay of the patients in the perioperative period, the rate of postoperative complications, the duration of the operation, decrease of postoperative pain level and early mobilization.

AIMS

We aimed to determine the effect of preoperative evidence-based care education that given to cardiac surgery clinical nurses on the postoperative recovery of patients.

METHODS

The research was planned as quasi-experimental. Eighty-six patients who underwent cardiovascular surgery were divided into control and intervention groups. First, the ongoing preoperative care practices and patient recovery outcomes of the clinic were recorded for the control group data. Second, education was provided for the clinical nurses about the preoperative evidence-based care list, and a pilot application was implemented. Finally, the evidence-based care list was applied by the nurses to the intervention group, and its effects on patient outcomes were evaluated. The data were collected using the preoperative evidence-based care list, descriptive information form, intraoperative information form and postoperative patient evaluation form.

RESULTS

The evidence-based care list was applied to the patients in the intervention group, with 100% adherence by the nurses. All pain level measurements in the intervention group were significantly lower in all measurements (p = .00). The body temperature measurements (two measurements) of the intervention group were higher (p = .00). The postoperative hospital stays of the control group and the intervention group were 11.21 ± 8.41 and 9.50 ± 3.61 days.

CONCLUSION

The presented preoperative evidence-based care list can be used safely in nursing practices for patients. It provides effective normothermia, reduces the level of pain, shortens the hospital stay and reduces the number of postoperative complications.

RELEVANCE TO CLINICAL PRACTICE

By applying a preoperative evidence-based care to patients undergoing cardiac surgery, pain levels, hospital stays and the number of complications decrease, and it is possible to maintain normothermia. An evidence-based care can be used to ensure rapid postoperative recovery for patients undergoing cardiac surgery.

Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study

OBJECTIVE

Enhanced recovery after cardiac surgery is a multidisciplinary clinical care pathway that relies on a bundle of interventions, aiming to reduce the stress response to surgery and promote early recovery of organ function. In 2011, our institution introduced an institutional enhanced recovery after cardiac surgery program focusing on 9 central interventions, which have been expanded during the past decade by additional interventions now considered standard of care. After the recent publication of the enhanced recovery after cardiac surgery guidelines, we evaluated the relation between the compliance with these enhanced recovery after cardiac surgery guidelines and postoperative outcomes.

METHODS

All patients enrolled in our enhanced recovery after cardiac surgery program in 2019 were included in this retrospective single-center audit. The primary outcome was compliance with 23 enhanced recovery after cardiac surgery guidelines. Secondary outcomes included occurrence of at least 1 postoperative complication and hospital length of stay.

RESULTS

A total of 356 patients were included in this study. Compliance with the enhanced recovery after cardiac surgery guidelines was 64%. Postoperatively, 51% of the patients experienced at least 1 complication and had a median hospital length of stay of 6 days. Multivariable analysis showed that an increased compliance (per 10%) with the enhanced recovery after cardiac surgery guidelines was associated with a lower risk for any complication (odds ratio, 0.60; 95% confidence interval, 0.46-0.79; P = .0003) and a higher probability of earlier hospital discharge (hazard ratio, 1.25; 95% confidence interval, 1.10-1.43; P = .0008).

CONCLUSIONS

This audit revealed a correlation between increased compliance with enhanced recovery after cardiac surgery guidelines and a reduction of postoperative complications and hospital length of stay. Future trials are needed to establish evidence-based recommendations for each separate intervention of the enhanced recovery after cardiac surgery guidelines and to create a minimum core-set of enhanced recovery after cardiac surgery interventions.

Comparison of Erector Spinae Plane Block and Pectointercostal Facial Plane Block for Enhanced Recovery After Sternotomy in Adult Cardiac Surgery

OBJECTIVES

This study aimed to investigate and compare the effects of the pectointercostal fascial plane block (PIFPB) and the erector spinae plane block (ESPB) on enhancing the recovery of patients who undergo cardiac surgery.

DESIGN

A randomized, controlled, double-blinded study.

SETTING

The operating rooms and intensive care units of university hospitals.

PARTICIPANTS

One hundred patients who were American Society of Anesthesiologists class II to III aged 18-to-70 years scheduled for elective cardiac surgery.

INTERVENTIONS

Patients were randomly assigned to undergo either ultrasound-guided bilateral PIFPB or ESPB.

MEASUREMENTS AND MAIN RESULTS

Patients shared comparable baseline characteristics. Time to extubation, the primary outcome, did not demonstrate a statistically significant difference between the groups, with median (95% confidence interval) values of 115 (90-120) minutes and 110 (100-120) minutes, respectively (p = 0.875). The ESPB group had a statistically significant reduced pain score postoperatively. The median (IQR) values of postoperative fentanyl consumption were statistically significantly lower in the ESPB group than in the PIFPB group (p < 0.001): 4 (4-5) versus 9 (9-11) µg/kg, respectively. In the ESPB group, the first analgesia request was given 4 hours later than in the PIFPB group (p < 0.001). Additionally, 12 (24%) patients in the PIFPB group reported nonsternal wound chest pain, compared with none in the ESPB group. The median intensive care unit length of stay for both groups was 3 days (p = 0.428).

CONCLUSIONS

Erector spinae plane block and PIFPB were found to equally affect recovery after cardiac surgery, with comparable extubation times and intensive care unit length of stay.

Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units

BACKGROUND

Anaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described.

OBJECTIVES

The objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU).

METHODS

A prospective, observational pilot study was implemented. Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia. The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed. Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2.

RESULTS

Fifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05).

CONCLUSIONS

In patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.

Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience

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.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Preemptive parasternal intercostal nerve block for patients undergoing off-pump coronary artery bypass grafting: a double-blind, randomized, controlled trial

Background

Parasternal intercostal nerve block has been increasingly used for postoperative analgesia and has shown that this technique can provide effective postoperative analgesia. This study aimed to investigate the effect of preemptive parasternal intercostal nerve block on the opioid and vasoactive drug dose required for intraoperative hemodynamic stability and postoperative analgesia in patients undergoing off-pump coronary artery bypass grafting.

Methods

In this prospective, randomized controlled study, 64 participants aged 45-75 years scheduled for off-pump coronary artery bypass grafting at The Second Xiangya Hospital of Central South University. Patients were randomized into two groups and preoperatively administered ropivacaine (group R) and saline (group S), in the parasternal intercostal spaces with ultrasound-guided bilateral nerve block.

Results

The primary outcome was intraoperative sufentanil and vasopressor dosage. The secondary outcomes were intraoperative hemodynamics, postoperative pain scores, and anesthesia recovery, postoperative use of rescue dezocine, stay in intensive care unit, and length of hospital stay. The consumption of intraoperative sufentanil and vasopressor was significantly lower in group R than in group S. The visual analog score in group R was significantly lower than that in group S up to 12 h postoperatively. The time to anesthesia recovery was significantly less in group R than in group S. Most patients in group S required rescue dezocine, whereas most patients in group R did not. The hemodynamic variables were stable in all patients.

Conclusions

A preemptive parasternal intercostal nerve block effectively reduced the required intraoperative sufentanil and norepinephrine dose and provided adequate analgesia for the first 12 h after surgery. Therefore, a preemptive parasternal intercostal nerve block is a good option for patients undergoing off-pump coronary artery bypass grafting.

Clinical trial registration

chictr.org.cn, identifier ChiCTR1800017210.

Bilateral Ultrasound-Guided Mid-Point Transverse Process to Pleura Block for Perioperative Analgesia in Pediatric Cardiac Surgery: A Randomized Controlled Study

OBJECTIVE

Mid-point transverse process to pleura (MTP) block is a new regional analgesia technique. This study aimed to assess the perioperative analgesic effects of MTP block in children undergoing open-heart surgery.

DESIGN

A single-center, randomized, double-blinded, controlled, superiority study.

SETTING

At a University Children's Hospital.

PARTICIPANTS

Fifty-two patients aged 2 to 10 years who underwent open-heart surgery.

INTERVENTIONS

Patients were randomized to receive either bilateral MTP block or no block (control).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was fentanyl consumption in the first postoperative 24 hours. The secondary outcomes were intraoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 4, 8, 16, and 24 hours after extubation, and the duration of stay in the intensive care unit (ICU). The mean (SD) postoperative fentanyl consumption (µg/kg) in the first 24 hours was significantly reduced in the MTP block group (4.4 ± 1.2) compared to the control group (6.0 ± 1.4, p < 0.001). The mean (SD) intraoperative fentanyl requirement (µg/ kg) was significantly reduced in the MTP block group (9.1 ± 1.9) compared to the control group (13.0 ± 2.1, p < 0.001). The MOPS was significantly reduced in the MTP block group compared to the control group at 1, 4, 8, and 16 hours after extubation but was comparable in both groups at 24 hours. The mean (SD) duration of ICU stay (hours) was significantly reduced in the MTP block group (25.0 ± 2.9) compared to the control group (30.7 ± 4.2, p < 0.001).

CONCLUSIONS

Single-shot bilateral ultrasound-guided MTP block in children undergoing cardiac surgery reduced the mean fentanyl consumption in the first postoperative 24 hours, intraoperative fentanyl requirements, pain score at rest, time to extubation, and duration of ICU stay.

The Association Between Enhanced Recovery After Cardiac Surgery-Guided Analgesics and Postoperative Delirium

OBJECTIVES

Delirium is a common postoperative complication associated with death and long-term cognitive impairment. The authors studied the association between opioid-sparing anesthetics, incorporating Enhanced Recovery After Cardiac Surgery (ERACS)-guided analgesics and postoperative delirium.

DESIGN

The authors performed a retrospective review of nonemergent coronary, valve, or ascending aorta surgery patients.

SETTING

A tertiary academic medical institution.

PARTICIPANTS

The study authors analyzed a dataset of elective adult cardiac surgical patients. All patients ≥18 years undergoing elective cardiac surgery from November 2, 2017 until February 2, 2021 were eligible for inclusion.

INTERVENTIONS

The ERACS-guided multimodal pain regimen included preoperative oral acetaminophen and gabapentin, and intraoperative intravenous lidocaine, ketamine, and dexmedetomidine.

MEASUREMENTS AND MAIN RESULTS

Delirium was measured by bedside nurses using the Confusion Assessment Method for the intensive care unit (ICU). Delirium occurred in 220 of the 1,675 patients (13.7%). The use of any component of the multimodal pain regimen was not associated with delirium (odds ratio [OR]: 0.85 [95% CI: 0.63-1.16]). Individually, acetaminophen was associated with reduced odds of delirium (OR: 0.60 [95% CI: 0.37-0.95]). Gabapentin (OR: 1.36 [95% CI: 0.97-2.21]), lidocaine (OR: 0.86 [95% CI: 0.53-1.37]), ketamine (OR: 1.15 [95% CI: 0.72-1.83]), and dexmedetomidine (OR: 0.79 [95% CI: 0.46-1.31]) were not individually associated with postoperative delirium. Individual ERACS elements were associated with secondary outcomes of hospital length of stay, ICU duration, postoperative opioid administration, and postoperative intubation duration.

CONCLUSIONS

The use of an opioid-sparing perioperative ERACS pain regimen was not associated with reduced postoperative delirium, opioid consumption, or additional poor outcomes. Individually, acetaminophen was associated with reduced delirium.

Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol

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.

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching

OBJECTIVE

To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG).

DESIGN

A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS.

SETTING

At a tertiary care teaching hospital.

PARTICIPANTS

A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β₂ coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods.

CONCLUSIONS

Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

The impact of a postoperative multimodal analgesia pathway on opioid use and outcomes after cardiothoracic surgery

OBJECTIVE

The Enhanced Recovery after Surgery Cardiac Society recommends using multimodal analgesia (MMA) for postoperative pain however, evidence-based guidelines have yet to be established. This study examines the impact of a standardized postoperative MMA pathway in reducing opioid consumption and related complications after cardiothoracic surgery (CTS).

METHODS

Within a multicenter healthcare system, a postoperative MMA pathway was developed and implemented at two CTS intensive care units (ICU) while the other CTS ICU opted to maintain the existing opioid-based pathway. A retrospective chart review was conducted on patients admitted to a CTS ICU within this healthcare system after conventional coronary artery bypass grafting and/or valve surgery from September 1, 2018, to June 30, 2019. Comparative analysis was conducted on patients prescribed MMA versus those managed with an opioid-based pathway. The primary outcome was total opioid consumption, converted to morphine milligram equivalents, 72-h post-surgery. Secondary outcomes included mobility within one-day post-surgery, ICU length of stay (LOS), time to first bowel movement (BM), and time to first zero Richmond Agitation-Sedation Scale (RASS).

RESULTS

Seven hundred sixty-two adults were included for final analysis. The MMA group had a higher body mass index, higher percentage of females, were more likely classified as African American and had higher scores for risk-adjusted complications. General Linear Model analysis revealed higher opioid consumption in the MMA group (Est. 0.22, p < 0.0009); however, this was not statistically significant after adjusting for differences in fentanyl usage. The MMA group was more likely to have mobility within one-day post-surgery (OR 0.44, p < 0.0001), have longer time to first BM (OR 1.93, p = 0.0011), and longer time to first zero RASS (OR 1.62, p = 0.0071). The analgesia groups were not a predictor for ICU LOS.

CONCLUSIONS

Opioid consumption was not reduced secondary to this postoperative MMA pathway. The MMA group was more likely to have mobility within one-day post-surgery. Patients in the MMA group were also more likely to have prolonged time to first BM and first zero RASS. Development and evaluation of a perioperative MMA pathway should be considered.

Effectiveness of Preventive Measures in the Inactive Course of Chronic Parenchymatic Mumps in Children

Aim: To study the effectiveness of preventive measures in the inactive course of chronic parenchymal mumps in remission. Materials and Methods: In the dynamics of precautionary measures, aimed at preventing of exacerbation of chronic processes in the parotid glands, were examined 29 children aged from 2 months to 16 years with inactive mumps in remission and 10 control persons aged from 7 to 15 years. Results: According to the assessment of the cellular composition of parotid secretion before anti-relapse measures in 9 patients out of 19, it was possible to detect the presence of latent chronic inflammation in symmetrical glands in the absence of classical clinical symptoms and clear secretion. After the completion of the treatment-and-prophylactic complex, the number of inflammatory cells and the degree of its contamination with microorganisms decreased significantly. Conclusions: The study of the composition of parotid secretion with taking into account of the results of ultrasound examination and sialography in the dynamic monitoring of chronic parenchymal mumps indicate its high diagnostic informativeness and allows a rational approach to planning preventive measures. The methodological approach, which was developed and tested by us and which was used in the active course of mumps, showed its high efficiency and inactive form of the disease, for the first year of observation the number of exacerbations decreased by 10 times, and for 5 years term- by 16 times, which allowed to prolong the remission period and improve the rheological properties of parotid secretion.

Comprehensive Rehabilitation of Cardiac Surgery Patients with Acute Left Ventricular Failure who Underwent Coronary Artery Bypass Grafting with Cardiopulmonary Bypass

Aim: To develop and implement a comprehensive rehabilitation of cardiosurgical patients with acute left ventricular failure who underwent on-pump coronary artery bypass grafting. Materials and Methods: 500 patients underwent on-pump coronary artery bypass grafting. Sixty patients who required inotropic support in the postoperative period were selected. The patients were divided into two groups of 30 people each. In both groups, psychological and physical rehabilitation was carried out in accordance with the algorithm developed by us. The protocol EACTS, 2017 for the main group was supplemented with a metabolic support component, the introduction of a combination of levocarnitine and arginine. Results: Psychological and physical algorithm was developed and implemented. In the basic group, the recovery time of hemodynamics and the total dose of the inotropic drug were shorter/lower than in the control one. Conclusions: Stressful moments informing the patient in the perioperative period is a powerful tool for psychological rehabilitation. Aerobic training and respiratory physiotherapy are mandatory elements of physical rehabilitation. The introduction of a combination of levocarnitine and arginine has a positive effect on the terms of activation of patients, and reduces the stay in the intensive care unit.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Different modalities of analgesia in open heart surgeries in Mansoura University

Background: Opioid usage in cardiac surgery is considered to be the corner stone in management. Inadequate pain control after cardiac surgery complicates patient recovery and increases the load on healthcare services. Multimodal analgesia can be used to achieve better analgesic effect and improves patient outcome.  Material and methods: A total of 90 patients undergoing cardiac surgery with median sternotomy were randomly allocated equally into three groups intraoperatively where first group received continuous infusion of high dose opioids, second group received boluses of low dose opioids and third group received multimodal non opioid analgesics including dexmedetomidine, ketamine and magnesium sulphate. All patients received the same post-operative analgesic regimen consists of morphine patient controlled analgesia (PCA). Results: Patients in multimodal non opioid group had more stable hemodynamics intra and postoperatively. Also, patients in multimodal group had lower pain scores extubation, earlier extubation, shorter ICU stay, earlier mobilization and earlier return of bowel movements compared to patients of both groups received intraoperative higher opioid doses.

Enhanced recovery after cardiac surgery and its impact on outcomes: A systematic review

BACKGROUND AND AIM

Enhanced Recovery After Surgery (ERAS) protocols are a series of perioperative interventions well-established in improving the care and outcomes of patients. With recent emergence of studies on its implementation in cardiac surgery, this paper represents the first systematic review on current evidence of ERAS efficacy in this field.

METHODS

Two reviewers independently searched through Pubmed, Cochrane, Google Scholar, Web of Science, Embase and Scopus. Comparative studies with controls that described the implementation of ERAS in all types of cardiac operations from 2001 to 2020 were included. Data extracted included patient demographics, components of ERAS protocol described, types of cardiac surgery, and postoperative outcomes.

RESULTS

In the final analysis, nine studies were included, of which there were one randomized controlled trial (RCT), one quasi-experiment and seven retrospective/prospective studies. Significant improvement in hospital and ICU length of stay, as well as reduction in postoperative opioid consumption were demonstrated. No increase in postoperative complications were reported.

CONCLUSION

ERAS in cardiac surgery has shown to be potentially safe and effective in improving certain postoperative outcomes. However, the evidence is limited by the lack of high-quality RCTs. We also found the lack of practice of class 1 recommended interventions set forth by the ERAS Cardiac Society. Furthermore, majority of studies only evaluated the immediate postoperative outcomes of patients, and not the long-term outcomes. RCTs that fully implement measures recommended by the ERAS Cardiac Society, with assessments on both immediate and long-term outcomes, are warranted.

Enhanced Recovery After Cardiac Surgery

The aims of "Fast track" cardiac anesthesia including shortening time to tracheal extubation and to hospital discharge in selected patients. The evidence is weak and recommendations are mostly based on observational, nonrandomized data and expert opinion. The majority of outcomes studied include: time to tracheal extubation, hospital/ICU length of stay, procedure-related financial costs, and the type/amount of opioids used in the peri-operative period. There should be a shift in focus to generating higher quality evidence supporting the use of enhanced recovery protocols in cardiac surgical patients and finding ways to tailor enhanced recovery principles to all cardiac surgical patients. Research should focus on the quality of care for individual patients and the delivery of health care to the public.

Comparison of Ultrasound-Guided Pectointercostal Fascial Block and Transversus Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management After Cardiac Surgery: A Prospective, Randomized, Double-Blind Pilot Study

OBJECTIVE

The objective of the present study was to evaluate morphine consumption and pain scores 24 hours postoperatively to compare the effects of a bilateral pectointercostal fascial block (PIFB) with those of a transversus thoracic muscle plane block (TTMPB) on acute poststernotomy pain in cardiac surgery patients who have undergone median sternotomy.

DESIGN

Prospective, randomized, double-blinded.

SETTING

The operating room, intensive care unit, and patient ward at a university hospital.

PARTICIPANTS

Thirty-nine American Society of Anesthesiologists II-to-III patients aged 18- to-80 years, scheduled for elective cardiac surgery via median sternotomy.

INTERVENTIONS

Patients randomly were allocated to groups scheduled to receive bilateral ultrasound-guided PIFB or TTMPB.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was postoperative morphine use within the first 24 hours. Secondary outcomes were the numerical pain rating scale (NRS) scores at rest and during coughing, time of first analgesic demand from the patient-controlled analgesia (PCA) device, and rescue analgesia use. The nausea/vomiting scores, time to extubation, length of stays in intensive care and the hospital, patient satisfaction scores, and complications were also recorded. The first 24-hour morphine use did not significantly differ between the PIFB and TTMPB groups (mean ± standard deviation [95% CI], 13.89 ± 6.80 [10.83-16.95] mg/24 h and 15.08 ± 7.42 [11.83-18.33] mg/24 h, respectively, p = 0.608). No significant difference between the two groups in the NRS scores at rest and during coughing was observed; the groups had similar requirements for rescue analgesia in the first 24 hours (n [%], three [15.8] and seven [35], p = 0.273, respectively). The time from PCA to the first analgesia request was longer in the PIFB than in the TTMPB group (median [interquartile range], 660 [540-900] minutes, and 240 [161-525] minutes, respectively, p = 0.002).

CONCLUSIONS

PIFB and TTMPB showed similar effectiveness for morphine consumption within 24 hours postoperatively and in pain scores in cardiac surgery patients.

Persistent Pain After Cardiac Surgery: Prevention and Management

Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.

Cardiac Enhanced Recovery After Surgery: Early Outcomes in a Community Setting

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in non-cardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results.

METHODS

We retrospectively analyzed 73 consecutive patients treated with ERAS care compared to 74 patients treated prior to implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization.

RESULTS

ERAS patients required significantly less opioids captured as total milligram morphine equivalents (MME; median: 35.0 versus 75.3, P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 versus 0.5, P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (POD 4: 95% vs 81%, P = .013) and postoperative length of stay was lower for ERAS care, but did not reach statistical significance (median 4 vs 5 days, P = .06). There was no difference in pain or glucose control or in early extubation.

CONCLUSIONS

Cardiac ERAS significantly decreased opioid use, nausea, lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital.

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study

STUDY OBJECTIVE

To evaluate the effectiveness of preoperative gabapentinoid administration.

DESIGN

Retrospective hospital registry study.

SETTING

Tertiary referral center (Boston, MA).

PATIENTS

111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018.

INTERVENTIONS

Preoperative administration of gabapentinoids (gabapentin or pregabalin).

MEASUREMENTS

We tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications.

MAIN RESULTS

Gabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [OR_adj] 0.80 [95% CI, 0.75-0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4-11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (OR_adj 0.74 [0.60-0.90]; p = 0.003), neuro-psychiatric complications (OR_adj 0.66 [0.49-0.87]; p = 0.004), non-surgical site infections (OR_adj 0.68 [0.52-0.88; p = 0.004) and trauma or poisoning (OR_adj 0.25 [0.16-0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (OR_adj 0.77 [0.70-0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (OR_adj 0.61 [0.50-0.75]; p < 0.001 and OR_adj 0.70 [0.53-0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (OR_adj 0.74 [0.65-0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery.

CONCLUSIONS

The preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.

Enhanced Recovery After Cardiac Surgery: A Propensity-Matched Analysis

Enhanced Recovery After Surgery (ERAS) pathways have improved clinical outcomes, cost-effectiveness, and patient satisfaction across multiple non-cardiac surgical specialties. Since the adaptation of ERAS in cardiac surgery is rapidly increasing yet still evolving, herein, we demonstrate early results of our implementation of ERAS cardiac guidelines. We retrospectively reviewed all patients who were managed with our institutional ERAS Cardiac Surgery guidelines between 5/2018 and 6/2019(N = 102). Postoperative primary outcomes (total ventilation times(hours), intensive-care unit(ICU) stay, and postoperative hospital length of stay (LOS)) were compared to 1:1 propensity matched controls from the pre ERAS era between January 2017 and March 2019. A total of 76 propensity-matched pairs were identified. Compared to the matched controls, ERAS patients had significantly shorter median ventilation times(3.5 vs. 5.3 hours, p = .01), ICU stays(median 28 vs 48 hours, p=.005) and postoperative hospital LOS (median 5 vs. 6 days, p = .03). There were no operative mortalities and no significant differences in 30-day readmission rates. There were also no significant differences in post-operative stroke, acute kidney injury, atrial fibrillation, and reoperation rates for bleeding. Two-year survival was also not statistically different between the two cohorts (p = .22). Our initial experience with implementation of ERAS protocols in cardiac surgery appear to demonstrate that these protocols are associated with shorter ventilation times, ICU stay, and hospital LOS without compromising patient outcomes. While these results are promising yet preliminary, further studies are warranted to demonstrate whether ERAS algorithms in cardiac surgery can consistently expedite postoperative recovery and improve outcomes.

Dexmedetomidine as an adjunctive analgaesic in the perioperative setting: A review of the literature

Though arguably past the initial phase of the opioid epidemic, opioid-sparing or opioid-eliminating pain management regimens remain beneficial for patients and practitioners alike. Providing adequate analgaesia without relying on opioids is especially advantageous in the operative setting, as patients may be able to recover without deep levels of sedation or the need for a high amount of opioid medications. Despite being used primarily as a sedative over the past 20 years, dexmedetomidine, a centrally acting alpha₂-agonist, possesses analgaesic properties, though its use has been limited by its well-described cardiovascular suppressive effects. The objective of this review was to determine the efficacy and safety of adjunctive dexmedetomidine for the purposes of analgaesia in the perioperative setting.

Pain intensity of sedated paediatric intensive care unit patients during treatment and care procedures

BACKGROUND

Although various pharmacological and non-pharmacological methods are used in the management of pain in the Paediatric Intensive Care Unit, patients experience more pain than those being treated in other units.

AIM AND OBJECTIVES

This study was conducted to determine the intensity of pain during invasive patient care and dressing change procedures in sedated paediatric intensive care unit (PICU) patients and to assess the impact of analgesics and demographic factors. The study also sought to evaluate any correlation between the face, legs, activity, cry, consolability (FLACC) and COMFORT scales.

DESIGN

The research was conducted as a descriptive cross-sectional study.

METHODS

The total sample size consisted of 30 mild-to-moderately sedated patients under the age of 18 in the PICU of a university hospital in Turkey between September the 1st, 2016, and December the 31st, 2016. The procedures were classified in to three groups: Invasive, Patient Care and Dressing Change. The FLACC and COMFORT scales were utilized to assess pain.

RESULTS

The intensity of pain did not differ according to the demographic characteristics (median [IQR]) by gender-COMFORT female: (16.05 [15.10-17.0]); male: (15.15 [14.7-16.5]) (P = .284)-age: (COMFORT: P = .165); intensive care admission indications: (COMFORT: P = .647); or administration of analgesics-COMFORT Yes: (15.90 [14.80-16.65]), No: (15.50 [14.70-16.45]) (P = .634). The invasive procedures produced the most intense pain (median [IQR]): FLACC: (5 [4-6])/COMFORT: (16 [15-20]). Patient care procedures were second in intensity of pain FLACC: (4 [3-5])/COMFORT: (15 [14-17]), while dressing changes produced significantly less pain FLACC: (3 [2-4])/COMFORT: (14 [12-17]) (P < .001). A positive correlation was noted between the pain scores observed on the FLACC and COMFORT scales (rs: Invasive procedures:0.992/Care procedure:0.991/Dressing procedures: 0.996) (P < .001).

CONCLUSIONS

Besides invasive procedures, patient care and dressing changes also cause sedated PICU patients' pain. The pain management was insufficient to prevent pain for most of the procedures in the PICU.

RELEVANCE TO CLINICAL PRACTICE

Besides making use of evidence-based pharmacological and non-pharmacological methods in invasive procedures, care must also be focused on preventing pain during patient care and dressing procedures so that the most effective treatment can be achieved.

Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial

IMPORTANCE

Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations.

OBJECTIVE

To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018.

INTERVENTION

Patients were randomized to standard bupivacaine or liposomal bupivacaine.

MAIN OUTCOMES AND MEASURES

Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption.

RESULTS

A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02111746.

Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review

Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.

Erector Spinae Regional Anesthesia for Robotic Coronary Artery Bypass Surgery Is Not Associated With Reduced Postoperative Opioid Use: A Retrospective Observational Study

OBJECTIVE

Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB).

DESIGN

This was a retrospective observational study of routinely recorded data.

SETTING

The study was performed at a single healthcare system.

PARTICIPANTS

All patients underwent robotic MIDCAB.

INTERVENTION

Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS.

MEASUREMENTS AND MAIN RESULTS

In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC.

CONCLUSIONS

These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.

Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients

Background

The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy.

Methods

Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision.

Results

Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block.

Conclusions

The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.

Postoperative Multimodal Analgesia in Cardiac Surgery

Multimodal pain management of cardiac surgical patients is a paradigm shift in postoperative care. This promising approach features complementary medications and techniques that spare opioids and improves symptomatic and functional recovery. Although the specific elements remain to be defined, the collaboration of the health care team and patient and continuous iterative programmatic improvements are important pillars of this approach.

Do perioperative protocols of enhanced recovery after cardiac surgery improve postoperative outcome?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the application of an enhanced recovery protocol or pathway improves patient outcomes after cardiac surgery. A total of 3091 papers were found using the reported search. Finally, 12 papers represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Six studies referred to enhanced recovery protocol as fast track (FT) and another 6 studies referred to it as enhanced recovery after surgery (ERAS). Significant differences from conventional care were reported for time to extubation or intubation time in 4 studies (3 FT, 1 ERAS), duration of intensive care unit stay in 6 studies (4 FT, 2 ERAS), length of hospital stay (LOS) in 8 studies (5 FT, 3 ERAS), cost in 5 studies (4 FT, 1 ERAS), pain scores in 2 studies (2 ERAS) and opioid use in 3 studies (3 ERAS). We conclude that FT or ERAS improve postoperative outcomes including length of stay and pain control, without increasing morbidity, mortality or readmission. However, there is a need for prospective studies and standardized protocols.