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

Preoperative Carbohydrate Load Does Not Alter Glycemic Variability in Diabetic and Non-Diabetic Patients Undergoing Major Gynecological Surgery: A Retrospective Study

Background/Objectives: Elevated glycemic variability (GV) has been associated with postoperative morbidity. Traditional preoperative fasting guidelines may contribute to high GV by driving the body into catabolism. Enhanced recovery after surgery (ERAS) protocols that include a preoperative carbohydrate load (PCL) reduce hospital length of stay and healthcare costs; however, it remains unclear whether PCL improves GV in surgical patients. The aim of this retrospective study was to determine the effect of a PCL on postoperative GV in diabetic and non-diabetic patients having gynecological surgery. Methods: Retrospective data were collected on patients who had gynecological surgery before and after the rollout of an institutional ERAS protocol that included PCL ingestion. The intervention group included patients who underwent surgery in 2019 and were enrolled in the ERAS protocol and, therefore, received a PCL. The control group included patients who underwent surgery in 2016 and, thus, were not enrolled in the protocol. The primary endpoint was GV, calculated by the coefficient of variance (CV) and glycemic lability index (GLI). Results: A total of 63 patients in the intervention group and 45 in the control were analyzed. GV was not statistically significant between the groups for CV (19.3% vs. 18.6%, p = 0.65) or GLI (0.58 vs. 0.54, p = 0.86). Postoperative pain scores (4.5 vs. 5.2 p = 0.23) and incentive spirometry measurements (1262 vs. 1245 p = 0.87) were not significantly different. A subgroup analysis of patients with and without type 2 diabetes mellitus revealed no significant differences in GV for any of the subgroups. Conclusions: This retrospective review highlights the need for additional GV research, including consensus agreement on a gold standard GV measurement. Large-scale prospective studies are needed to test the effectiveness of the PCL in reducing GV.

First initiation of mobilization out of bed after cardiac surgery - an observational cross-sectional study in Sweden

BACKGROUND

Cardiac surgery is associated with a period of postoperative bed rest. Although early mobilization is a vital component of postoperative care, for preventing complications and enhancing physical recovery, there is limited data on routine practices and optimal strategies for early mobilization after cardiac surgery. The aim of the study was to define the timing for the first initiation of out of bed mobilization after cardiac surgery and to describe the type of mobilization performed.

METHODS

In this observational study, the first mobilization out of bed was studied in a subset of adult cardiac surgery patients (n = 290) from five of the eight university hospitals performing cardiothoracic surgery in Sweden. Over a five-week period, patients were evaluated for mobilization routines within the initial 24 h after cardiac surgery. Data on the timing of the first mobilization after the end of surgery, as well as the duration and type of mobilization, were documented. Additionally, information on patient characteristics, anesthesia, and surgery was collected.

RESULTS

A total of 277 patients (96%) were mobilized out of bed within the first 24 h, and 39% of these patients were mobilized within 6 h after surgery. The time to first mobilization after the end of surgery was 8.7 ± 5.5 h; median of 7.1 [4.5-13.1] hours, with no significant differences between coronary artery bypass grafting, valve surgery, aortic surgery or other procedures (p = 0.156). First mobilization session lasted 20 ± 41 min with median of 10 [1-11]. Various kinds of first-time mobilization, including sitting on the edge of the bed, standing, and sitting in a chair, were revealed. A moderate association was found between longer intubation time and later first mobilization (ρ = 0.487, p < 0.001). Additionally, there was a moderate correlation between the first timing of mobilization duration of the first mobilization session (ρ = 0.315, p < 0.001).

CONCLUSIONS

This study demonstrates a median time to first mobilization out of bed of 7 h after cardiac surgery. A moderate correlation was observed between earlier timing of mobilization and shorter duration of the mobilization session. Future research should explore reasons for delayed mobilization and investigate whether earlier mobilization correlates with clinical benefits.

TRIAL REGISTRATION

FoU in VGR (Id 275,357) and Clinical Trials (NCT04729634).

Trends in preoperative carbohydrate load practice: A systematic review

BACKGROUND

The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice.

METHODS

A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume.

RESULTS

A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377).

CONCLUSION

Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.

Enhanced recovery protocols after surgery: A systematic review and meta-analysis of randomized trials in cardiac surgery

BACKGROUND

Previous meta-analyses combining randomized and observational evidence in cardiac surgery have shown positive impact of enhanced recovery protocols after surgery (ERAS) on postoperative outcomes. However, definitive data based on randomized studies are missing, and the entirety of the ERAS measures and pathway, as recently systematized in guidelines and consensus statements, have not been captured in the published studies. The available literature actually focuses on "ERAS-like" protocols or only limited number of ERAS measures. This study aims at analyzing all randomized studies applying ERAS-like protocols in cardiac surgery for perioperative outcomes.

METHODS

A meta-analysis of randomized controlled trials (RCTs) comparing ERAS-like with standard protocols of perioperative care was performed (PROSPERO registration CRD42021283765). PRISMA guidelines were used for abstracting and assessing data.

RESULTS

Thirteen single center RCTs (N = 1704, 850 in ERAS-like protocol and 854 in the standard care group) were selected. The most common procedures were surgical revascularization (66.3%) and valvular surgery (24.9%). No difference was found in the incidence of inhospital mortality between the ERAS and standard treatment group (risk ratio [RR] 0.61 [0.31; 1.20], p = 0.15). ERAS was associated with reduced intensive care unit (standardized mean difference [SMD] -0.57, p < 0.01) and hospital stay (SMD -0.23, p < 0.01) and reduced rates of overall complications when compared to the standard protocol (RR 0.60, p < 0.01) driven by the reduction in stroke (RR 0.29 [0.13; 0.62], p < 0.01). A significant heterogeneity in terms of the elements of the ERAS protocol included in the studies was observed.

CONCLUSIONS

ERAS-like protocols have no impact on short-term survival after cardiac surgery but allows for a faster hospital discharge while potentially reducing surgical complications. However, this study highlights a significant nonadherence and heterogeneity to the entirety of ERAS protocols warranting further RCTs in this field including a greater number of elements of the framework.

Revolutionizing Surgical Care: The Power of Enhanced Recovery After Surgery (ERAS)

The development of Enhanced Recovery After Surgery (ERAS) has brought about substantial transformations in perioperative care, substituting conventional methods with a patient-centric, evidence-based strategy. ERAS protocol adopts a holistic approach to patient care, which includes all stages preceding, during, and following the operation. These programs prioritize patient-specific therapies that are tailored to their specific requirements. Nutritional assessment and enhancement, patient education, minimally invasive procedures, and multimodal pain management are all fundamental components of ERAS. ERAS provides a multitude of advantages, including diminished postoperative complications, abbreviated hospital stays, heightened patient satisfaction, and healthcare cost reductions. This article examines the foundational tenets of ERAS, their incorporation into the field of general surgery, their suitability for diverse surgical specialties, the obstacles faced during implementation, and possible directions for further investigation, such as the integration of digital health technologies, personalized patient care, and the long-term viability of ERAS protocols.

Aortic Valve Replacement and Repair With or Without Concomitant Ascending Aorta Replacement: Impact on Outcomes: A Systematic Review

Aortic valve surgery is a common procedure used to treat significant aortic valve stenosis or insufficiency. Some of these patients have coexisting pathology affecting the ascending aorta requiring ascending aorta replacement (AAR). Although the outcomes of these procedures are independently positive, it is proposed that concomitant AAR improves outcomes and minimizes the chances of future ascending aorta replacement. A comprehensive literature search for relevant studies published since 2010 comparing outcomes of aortic valve repair and replacement with or without concomitant ascending aorta replacement was undertaken using electronic databases PubMed, Cochrane Library, Embase Ovid, and SCOPUS. Major exclusion criteria were (1) conference posters, literature reviews, editorials; (2) aortic root surgery, aortic arch surgery, or other surgeries (3) case series with less than 5 participants. A total of 1189 patients from 6 retrospective cohort studies were included in the final review, from which clinical outcomes such as mortality and complications were compared. Mortality rates were similar in both intervention groups. No significant differences were found between the 2 groups in reexploration rates due to bleeding, stroke, postoperative dialysis, and atrial fibrillation. Survival rates varied but had no significant difference between interventions. Both isolated aortic valve surgery and concomitant AAR procedures offer comparable favourable outcomes in terms of mortality, survival rates, and complication risks. However, the evidence is limited by the lack of randomized controlled trials. We recommend that future studies should standardize reporting on postoperative recovery, complications, long-term freedom from reoperations, and long-term changes to aorta dimensions.

Erector spinae plane block for postoperative analgesia in cardiac surgeries- A systematic review and meta-analysis

Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of ESPB in cardiac surgeries. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar to identify the studies in which ESPB was compared with the control group/sham block in patients undergoing cardiac surgeries. The primary outcomes were postoperative opioid consumption and postoperative pain scores. The secondary outcomes were intraoperative opioid consumption, ventilation time, time to the first mobilization, length of ICU and hospital stay, and adverse events. Out of 607 studies identified, 16 studies (n = 1110 patients) fulfilled inclusion criteria and were used for qualitative and quantitative analysis. Although, 24-hr opioid consumption were comparable in both groups group (MD, -18.74; 95% CI, -46.85 to 9.36, P = 0.16), the 48-hr opioid consumption was significantly less in ESPB group than control ((MD, -11.01; 95% CI, -19.98 to --2.04, P = 0.02). The pain scores at various time intervals and intraoperative opioid consumption were significantly less in ESPB group. Moreover, duration of ventilation, time to the first mobilization, and length of ICU and hospital were also less in ESPB group (P < 0.00001, P < 0.00001, P < 0.00001, and P < 0.0001, respectively). This systematic review and meta-analysis demonstrated that ESPB provides opioid-sparing perioperative analgesia, facilitates early extubation and mobilization, leads to early discharge from ICU and hospital, and has lesser pruritus when compared to control in patients undergoing cardiac surgeries.

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.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study

OBJECTIVES

The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery.

DESIGN

A retrospective observational study.

SETTING

A single large teaching hospital.

PARTICIPANTS

A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data.

INTERVENTIONS

Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications.

MEASUREMENTS AND MAIN RESULTS

The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups.

CONCLUSIONS

Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

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.

Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop

OBJECTIVE(S)

In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact.

METHODS

Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes.

RESULTS

Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop.

CONCLUSIONS

Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.