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Rouhi AD, Roberson JL, Alberstadt AN, Shah SK, Maurer M, Bader E, Williams NN, Dumon KR. Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study. J Surg Res 2024; 299:43-50. [PMID: 38701703 DOI: 10.1016/j.jss.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/13/2024] [Accepted: 04/07/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures. METHODS Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access. RESULTS 912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035). CONCLUSIONS Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.
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Affiliation(s)
- Armaun D Rouhi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey L Roberson
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angelika N Alberstadt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Simrin Kesmia Shah
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Madeline Maurer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Bader
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noel N Williams
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristoffel R Dumon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Wang DS. Pro: Early Full Nutrition is Beneficial in the Critically Ill Population. J Cardiothorac Vasc Anesth 2024; 38:1428-1430. [PMID: 38395725 DOI: 10.1053/j.jvca.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Affiliation(s)
- David S Wang
- Department of Anesthesiology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [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: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Peng Y, Chen M, Ni H, Li S, Chen L, Lin Y. Effect of timing of enteral nutrition initiation on poor prognosis in patients after cardiopulmonary bypass: A prospective observational study. Nutrition 2023; 116:112197. [PMID: 37741090 DOI: 10.1016/j.nut.2023.112197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/09/2023] [Accepted: 08/13/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES Current guidelines recommend that enteral nutrition (EN) be implemented as early as possible in patients after cardiopulmonary bypass (CPB), but the optimal time to initiate EN remains controversial. Therefore, the aim of this study was to investigate the effect of timing of EN initiation on poor prognosis in patients after CPB. METHODS This was a prospective observational study with patients who underwent CPB in a tertiary hospital from September 1, 2021, to January 31, 2022. The patients were divided into three groups according to the timing of EN initiation: <24 h, 24 to 48 h, and >48 h. Unconditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals to identify independent risk factors for poor prognosis. RESULTS The study included 579 patients, of whom 255 patients had EN initiated at <24 h (44%), 226 at 24 to 48 h (39%), and at >48 h (17%). With EN <24 h as a reference, multivariate logistic analysis showed that EN 24 to 48 h (OR, 1.854, P = 0.008) and EN >48 h (OR, 7.486, P <0.001) were independent risk factors for poor prognosis after CPB. Age (OR, 1.032, P = 0.001), emergency surgery (OR, 10.051; P <0.001), surgical time (OR, 1.006; P <0.001), and sequential organ failure assessment score (OR, 1.269; P = 0.001) also increased the risk for poor prognosis after CPB. CONCLUSIONS Compared with early EN <24 h, EN 24 to 48 h and EN >48 h increased the risk for poor prognosis in patients after CPB.
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Affiliation(s)
- Yanchun Peng
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meihua Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hong Ni
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sailan Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
| | - Yanjuan Lin
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China; Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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Wang X, Li Y, Ye J, Jiang F, Cheng Y, Chen X. The Prognostic Value of Johns Hopkins Hospital Nutrition Support Score in Older Patients Undergoing Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2023; 37:1959-1966. [PMID: 37516594 DOI: 10.1053/j.jvca.2023.06.038] [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: 04/03/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES Clarify the prognostic value of the Johns Hopkins Hospital Nutrition Support (JHHNS) score on clinical outcomes in older patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). DESIGN A retrospective observational study. SETTING A teaching and university hospital and tertiary referral center. PARTICIPANTS The authors analyzed 328 older patients aged ≥65 who underwent cardiovascular surgery with CPB in 2020. INTERVENTIONS Malnutrition risk was identified by the JHHNS score calculated based on specific preoperative and intraoperative objective parameters. Patients were divided into low- and high-JHHNS groups. Early morbidity, including pneumonia, bacteremia, wound infection, cerebrovascular accident, gastrointestinal bleeding, acute kidney injury, delirium, requirement for extracorporeal membrane oxygenation, and readmission to the intensive care unit (ICU), were the primary outcome; whereas in-hospital mortality, length of ICU and hospital stay, duration of mechanical ventilation and short-term mortality were secondary outcomes. The independent risk factors for postoperative complications were analyzed by logistic regression analyses. MEASUREMENTS AND MAIN RESULTS The JHHNS score identified 21.0% of patients at risk for malnutrition. Patients in the high-JHHNS group had prolonged median length hospital stay (21 v 24 days, p = 0.002) and mechanical ventilation (13.0 v 16.0 hours, p = 0.038), and more patients in this subgroup stayed longer than 3 days in ICU (30.1% v 43.5%, p = 0.036). Besides, they experienced more postoperative complications (11.2% v 39.1%, p < 0.001). Furthermore, multivariate logistic regression analysis demonstrated that the JHHNS score independently predicted the risk of postoperative complications. No significant intergroup difference was observed for the short-term mortality. CONCLUSIONS The JHHNS score was an independent predictor for postoperative complications but did not significantly affect short-term mortality in older patients undergoing cardiovascular surgery with CPB.
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Affiliation(s)
- Xiaoqian Wang
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yuan Li
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Jiaxin Ye
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Fengjuan Jiang
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yongqing Cheng
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Xiaotian Chen
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China.
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Gao W, Li H, Chen Y, Zhang Y, Zhang M, Jin J. Effectiveness of a short-term multimodal prehabilitation program in adult patients awaiting selective cardiac surgery: study protocol for an open-label, pilot, randomized controlled trial. Front Cardiovasc Med 2023; 10:1201737. [PMID: 37456818 PMCID: PMC10347384 DOI: 10.3389/fcvm.2023.1201737] [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: 04/07/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Background Prehabilitation has been demonstrated to positively impact postoperative recovery in patients undergoing selective cardiac surgery. However, the optimal modules included in prehabilitation programs are yet to be fully explored, as existing studies have primarily focused on exercise. This study will explore the effectiveness of a three-arm prehabilitation program among adult patients awaiting selective cardiac surgery. Methods and analysis A single-center, parallel-group randomized controlled trial will be conducted at the Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU). A total of 152 adult patients scheduled for elective cardiac surgery (coronary artery bypass grafting or valvular surgery) will be recruited from a tertiary teaching hospital. The patients will be randomly assigned to either the control group or the prehabilitation group. Patients assigned to the control group will receive standard care, which includes patient education and counseling as well as personal guidance on exercise, breathing, and coughing. Patients in the intervention group will be provided a multimodal prehabilitation program, including nutrition guidance, a diet journal, mindfulness training, and exercise guidance. The interventions will begin with home-based training and continue after hospital admission and before surgery. The primary outcome will be the perioperative 6-minute walk distance (6 MWD). The secondary outcomes will include preoperative readiness, postoperative recovery, and patient experience with the program. Discussion The purpose of the study is to examine whether a short-term multimodal prehabilitation program will be associated with improved preoperative readiness and postoperative outcomes. The findings of this study will provide evidence to support the development of a perioperative program aimed at enhancing patient recovery. Clinical Trial Registration www.ClinicalTrials.gov; identifier: NCT05503004.
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Affiliation(s)
- Wen Gao
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Emergency Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hongyan Li
- Department of Rehabilitation, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yuaner Chen
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Mao Zhang
- Emergency Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University, Hangzhou, China
| | - Jingfen Jin
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University, Hangzhou, China
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Effects of preoperative nutritional status on disability-free survival after cardiac and thoracic aortic surgery: a prospective observational study. J Anesth 2023; 37:401-407. [PMID: 36929443 DOI: 10.1007/s00540-023-03178-4] [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: 01/05/2023] [Accepted: 03/04/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE Preoperative malnutrition is associated with postoperative complications, prolonged intensive care unit stay, and mortality, leading to functional disability after non-cardiac surgery. However, its effects on cardiac and thoracic aortic surgery outcomes remain unknown. We examined the effects of preoperative malnutrition on disability-free survival after surgery and assessed the perioperative 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS2.0) score based on the preoperative nutritional status. METHODS We included individuals aged ≥ 55 years who underwent elective cardiac and/or thoracic aortic surgery between April 1, 2016 and December 28, 2018 in a tertiary center. The nutritional status was assessed preoperatively using the Mini Nutritional Assessment Short Form, with scores < 12 points indicating a poor nutritional status. The JapanSCORE2 was calculated for surgical risk prediction. Our primary outcome was disability-free survival 1 year after surgery (WHODAS2.0 score: < 16%). The odds ratio of poor nutritional status for disability-free survival was calculated using multiple logistic regression analysis after adjusting for age, JapanSCORE2, and duration of surgery. RESULTS One hundred patients were followed up for 1 year. Preoperatively, 41 of them had a poor nutritional status. The disability-free survival rates 1 year postoperatively were 46.3% (19/41) and 64.4% (38/59) in patients with and without poor preoperative nutritional status, respectively. The adjusted odds ratio of poor nutritional status for disability-free survival at 1 year after surgery was 0.42 (95% confidence interval, 0.17-0.99). CONCLUSION Patients with a poor preoperative nutritional status had less likely to show disability-free survival 1 year after cardiac and thoracic aortic surgery.
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Liu Z, Zang W, Zhang P, Shen Z. Prognostic implications of Global Leadership Initiative on Malnutrition-defined malnutrition in older patients who underwent cardiac surgery in China. Surgery 2023; 173:472-478. [PMID: 36494275 DOI: 10.1016/j.surg.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/04/2022] [Accepted: 11/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The proportion of older patients who are candidates for cardiac surgery is increasing. Growing evidence has shown that malnutrition is associated with a poor prognosis after cardiac surgery. The present study aimed to investigate the prognostic implications of malnutrition defined by the Global Leadership Initiative on Malnutrition in older patients who underwent cardiac surgery. METHODS From November 2015 to January 2021, 401 older patients who underwent cardiac surgery were retrospectively enrolled and evaluated using the Global Leadership Initiative on Malnutrition criteria. The perioperative characteristics and clinical outcomes were collected. The independent risk factors for postoperative complications and overall survival were analyzed. RESULTS The prevalence of Global Leadership Initiative on Malnutrition-defined malnutrition was 22.7% in this study. Patients with Global Leadership Initiative on Malnutrition-defined malnutrition had higher risks of postoperative complications (65.9% vs 49.7%, P = .006) and poor overall survival (68.1% vs 83.9%, P = .0019). Global Leadership Initiative on Malnutrition-defined malnutrition was also related to a longer postoperative hospital stay and prolonged intensive care stay. Five factors were identified as independent risk factors for overall survival: Global Leadership Initiative on Malnutrition-defined malnutrition (P = .009), chronic heart failure (P = .007), atrial fibrillation (P = .029), operative time (P < .001) and hemoglobin (P = .044). CONCLUSION We demonstrated the prognostic implications of Global Leadership Initiative on Malnutrition-defined malnutrition in older patients who underwent cardiac surgery for the first time. This study highlights the necessity of using the Global Leadership Initiative on Malnutrition assessment in the comprehensive preoperative risk assessment of cardiac surgery.
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Affiliation(s)
- Zhang Liu
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wangfu Zang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peng Zhang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
| | - Zile Shen
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [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: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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Prognostic Effect of Thoracic Sarcopaenia on Short- and Long-Term Clinical Outcomes in Patients Underwent Cardiac Valve Surgery. Heart Lung Circ 2022; 31:1408-1418. [PMID: 35961821 DOI: 10.1016/j.hlc.2022.05.041] [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: 02/28/2022] [Revised: 05/05/2022] [Accepted: 05/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND As the proportion of elderly patients increases, higher incidence of malnutrition is found among patients with valvular heart disease. Sarcopaenia is one of the main manifestations of malnutrition. Studies have shown the certain predictive effect of sarcopaenia on the clinical outcome in different cases. This study aims to clarify the impact of computed tomography (CT)-derived thoracic sarcopaenia on clinical outcomes of patients underwent cardiac valve surgery. METHODS The clinical data of 216 patients who underwent cardiac valve surgery from December 2015 to June 2020 were retrospectively collected. Skeletal muscle mass at 12th thoracic vertebra level was measured to diagnose thoracic sarcopaenia. Postoperative complications and follow-up data were collected. Medium follow-up was 3.2 years. RESULTS The prevalence of thoracic sarcopaenia was 16.7% in this study. The incidence of total complications and in-hospital mortality were higher in thoracic sarcopaenia group (p=0.024 and p=0.014, respectively). Multivariate analysis revealed that thoracic sarcopaenia is a significant predictor for postoperative complications (OR 2.319; 95% CI 1.003-5.366; p=0.049). Decreased long-term survival was observed in patients with thoracic sarcopaenia. Thoracic sarcopaenia (HR 4.178; 95% CI 2.062-8.465; p<0.001) was determined to be an independent risk factor for late mortality. CONCLUSION Thoracic sarcopaenia defined by chest CT was independently associated with higher incidence of postoperative complications and long-term mortality. Routine preoperative evaluation of thoracic sarcopaenia deserves further consideration to enhance the predictive performance for operation risk.
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Preoperative Phase Angle as a Risk Indicator in Cardiac Surgery-A Prospective Observational Study. Nutrients 2022; 14:nu14122491. [PMID: 35745221 PMCID: PMC9228129 DOI: 10.3390/nu14122491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The phase angle (PhA) can be used for prognostic assessments in critically ill patients. This study describes the perioperative course of PhA and associated risk indicators in a cohort of elective cardiac surgical patients. Methods: The PhA was measured in 168 patients once daily until postoperative day (POD) seven. Patients were split into two groups depending on their median preoperative PhA and analyzed for several clinical outcomes; logistic regression models were used. Results: The PhA decreased from preoperative (6.1° ± 1.9°) to a nadir on POD 2 (3.5° ± 2.5°, mean difference −2.6° (95% CI, −3.0°; −2.1°; p < 0.0001)). Patients with lower preoperative PhA were older (71.0 ± 9.1 vs. 60.9 ± 12.0 years; p < 0.0001) and frailer (3.1 ± 1.3 vs. 2.3 ± 1.1; p < 0.0001), needed more fluids (8388 ± 3168 vs. 7417 ± 2459 mL, p = 0.0287), and stayed longer in the ICU (3.7 ± 4.5 vs. 2.6 ± 3.8 days, p = 0.0182). Preoperative PhA was independently influenced by frailty (OR 0.77; 95% CI 0.61; 0.98; p = 0.0344) and cardiac function (OR 1.85; 95%CI 1.07; 3.19; p = 0.028), whereas the postoperative PhA decline was independently influenced by higher fluid balances (OR 0.86; 95% CI 0.75; 0.99; p = 0.0371) and longer cardiopulmonary bypass times (OR 0.99; 95% CI 0.98; 0.99; p = 0.0344). Conclusion: Perioperative PhA measurement is an easy-to-use bedside method that may critically influence risk evaluation for the outcome of cardiac surgery patients.
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Martínez-Ortega AJ, Piñar-Gutiérrez A, Serrano-Aguayo P, González-Navarro I, Remón-Ruíz PJ, Pereira-Cunill JL, García-Luna PP. Perioperative Nutritional Support: A Review of Current Literature. Nutrients 2022; 14:nu14081601. [PMID: 35458163 PMCID: PMC9030898 DOI: 10.3390/nu14081601] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/27/2022] [Accepted: 04/09/2022] [Indexed: 02/04/2023] Open
Abstract
Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.
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Vinck EE, van Ierland KM, Rendón JC, Escobar JJ, Quintero Gómez A, Saldarriaga CI, van Brakel T, Klautz RJM, Cárdenas D. Peri-operative nutrition in cardiovascular surgery: current pitfalls and future directions. Acta Chir Belg 2022; 122:77-84. [PMID: 34913838 DOI: 10.1080/00015458.2021.2020009] [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: 10/19/2022]
Abstract
In the field of cardiovascular surgery, many areas are frequently evaluated to improve patient outcomes. Even though cardiac surgery has advanced significantly, peri-operative nutrition remains an area needing special attention and is under-considered in patient results. The three portions of cardiac surgical nutrition optimization are pre-operative, intra-operative and post-operative. All these, merit important clinical intervention which when done properly can significantly improve patient recovery and reduce morbidity and mortality. Here we provide a narrative review and recommendations for peri-operative nutritional optimization in cardiac surgery.
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Affiliation(s)
- Eric E. Vinck
- Department of Cardiovascular Surgery, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Colombia
| | | | - Juan C. Rendón
- Department of Cardiovascular Surgery, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Colombia
| | - José J. Escobar
- Department of Cardiovascular Surgery, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Colombia
| | - Alejandro Quintero Gómez
- Department of Cardiovascular Surgery, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Colombia
| | - Clara I. Saldarriaga
- Department of Cardiology and Heart Failure, Cardio VID Clinic, Medellín, Colombia
| | - Thomas van Brakel
- Department of Cardio-thoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Robert J. M. Klautz
- Department of Cardio-thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Diana Cárdenas
- Department of Clinical Nutrition, El Bosque University, Bogota, Colombia
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Impact of oral or enteral nutritional support on clinical outcomes of patients subjected to cardiac surgery: a systematic review. Clin Nutr ESPEN 2022; 49:28-39. [DOI: 10.1016/j.clnesp.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 11/24/2022]
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15
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Seoudy H, Al-Kassou B, Shamekhi J, Sugiura A, Frank J, Saad M, Bramlage P, Seoudy AK, Puehler T, Lutter G, Schulte DM, Laudes M, Nickenig G, Frey N, Sinning JM, Frank D. Frailty in patients undergoing transcatheter aortic valve replacement: prognostic value of the Geriatric Nutritional Risk Index. J Cachexia Sarcopenia Muscle 2021; 12:577-585. [PMID: 33764695 PMCID: PMC8200421 DOI: 10.1002/jcsm.12689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Malnutrition is a hallmark of frailty, is common among elderly patients, and is a predictor of poor outcomes in patients with severe symptomatic aortic stenosis (AS). The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established screening tool to predict the risk of morbidity and mortality in elderly patients. In this study, we evaluated whether GNRI may be used in the risk stratification and management of patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Patients with symptomatic severe AS (n = 953) who underwent transfemoral TAVR at the University Hospital Schleswig-Holstein Kiel, Germany, between 2010 and 2019 (development cohort) were divided into two groups: normal GNRI ≥ 98 (no nutrition-related risk; n = 618) versus low GNRI < 98 (at nutrition-related risk; n = 335). The results were validated in an independent (validation) cohort from another high-volume TAVR centre (n = 977). RESULTS The low-GNRI group had a higher proportion of female patients (59.1% vs. 52.1%), higher median age (82.9 vs. 81.8 years), prevalence of atrial fibrillation (50.4% vs. 40.0%), median logistic EuroSCORE (17.5% vs. 15.0%) and impaired left ventricular function (<35%: 10.7% vs. 6.8%), lower median estimated glomerular filtration rate (50 vs. 57 mL/min/1.73 m2 ) and median albumin level (3.5 vs. 4.0 g/dL) compared with the normal-GNRI group. Among peri-procedural complications, Acute Kidney Injury Network (AKIN) Stage 3 was more common in the low-GNRI group (3.6% vs. 0.6%, p = 0.002). After a mean follow-up of 21.1 months, all-cause mortality was significantly increased in the low-GNRI group compared with the normal-GNRI group (p < 0.001). This was confirmed in the validation cohort (p < 0.001). Low GNRI < 98 was identified as an independent risk factor for all-cause mortality (hazard ratio 1.44, 95% CI 1.01-2.04, p = 0.043). Other independent risk factors included albumin level < median of 4.0 g/dL, high-sensitive troponin T in the highest quartile (> 45.0 pg/mL), N-terminal pro-B-type natriuretic peptide in the highest quartile (> 3595 pg/mL), grade III-IV tricuspid regurgitation, pulmonary arterial hypertension, life-threatening bleeding, AKIN Stage 3 and disabling stroke. CONCLUSIONS Low GNRI score was associated with an increased risk of all-cause mortality in patients undergoing TAVR, implying that this vulnerable group may benefit from improved preventive measures.
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Affiliation(s)
- Hatim Seoudy
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Kiel, Kiel, Germany.,Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Kiel, Germany
| | | | | | | | - Johanne Frank
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Kiel, Kiel, Germany.,Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Kiel, Germany
| | - Mohammed Saad
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Kiel, Kiel, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Anna Katharina Seoudy
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Clinical Nutrition, University of Kiel, Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Kiel, Kiel, Germany
| | - Georg Lutter
- Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Kiel, Germany.,Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Kiel, Kiel, Germany
| | - Dominik M Schulte
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Clinical Nutrition, University of Kiel, Kiel, Germany
| | - Matthias Laudes
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Clinical Nutrition, University of Kiel, Kiel, Germany
| | - Georg Nickenig
- Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Norbert Frey
- Department of Cardiology, Heidelberg University, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Derk Frank
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein Kiel, Kiel, Germany.,Partner Site Hamburg/Kiel/Lübeck, German Centre for Cardiovascular Research, Kiel, Germany
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16
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Stuhlreyer J, Klinger R. Development and Validation of the Pain and State of Health Inventory (PHI): Application for the Perioperative Setting. J Clin Med 2021; 10:1965. [PMID: 34063725 PMCID: PMC8124984 DOI: 10.3390/jcm10091965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
Currently, general measurements and evaluations of the quality of recovery are difficult because no adequate measuring tools are available. Therefore, there is an urgent need for a universal tool that assesses patient-relevant criteria-postoperative pain, state of health, and somatic parameters. For this purpose, a pain and state of health inventory (PHI, Schmerz- und Befindlichkeitsinventar (SBI) in German) has been developed. In this study, we describe its development and validation. The development phase was led by an expert panel and was divided into three subphases: determining the conceptual structure, testing the first editions, and adjusting the inventory for a finalized edition. For the purpose of validation, the PHI was filled in by 132 patients who have undergone total knee replacement and was analyzed using principal component analysis. Construct validity was tested by correlating the items with validated questionnaires. The results showed that the inventory can test pain, state of health, and somatic parameters with great construct validity. Furthermore, the inventory is accepted by patients, map changes, and supports to initiate adequate treatment. In conclusion, the PHI is a universal tool that can be used to assess the quality of recovery in the perioperative setting and allow immediate intervention.
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Affiliation(s)
- Julia Stuhlreyer
- Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
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17
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Zaouter C, Damphousse R, Moore A, Stevens LM, Gauthier A, Carrier FM. Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:746-765. [PMID: 33589344 DOI: 10.1053/j.jvca.2021.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Cédrick Zaouter
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Remy Damphousse
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louis-Mathieu Stevens
- Department of Surgery, Division of Cardiac surgery, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alain Gauthier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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20
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Kubitz JC, Schulte-Uentrop L, Zoellner C, Lemke M, Messner-Schmitt A, Kalbacher D, Sill B, Reichenspurner H, Koell B, Girdauskas E. Establishment of an enhanced recovery after surgery protocol in minimally invasive heart valve surgery. PLoS One 2020; 15:e0231378. [PMID: 32271849 PMCID: PMC7145109 DOI: 10.1371/journal.pone.0231378] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/21/2020] [Indexed: 12/13/2022] Open
Abstract
Protocols for “Enhanced recovery after surgery (ERAS)” are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.
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Affiliation(s)
- Jens C. Kubitz
- Department of Anaesthesiology, University Medical Center Eppendorf, Hamburg, Germany
- * E-mail:
| | | | - Christian Zoellner
- Department of Anaesthesiology, University Medical Center Eppendorf, Hamburg, Germany
| | - Melanie Lemke
- Department of Physiotherapy, University Medical Center Eppendorf, Hamburg, Germany
| | | | - Daniel Kalbacher
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Björn Sill
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Benedikt Koell
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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