Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

Deep Serratus Anterior Plane Block for Multimodal Analgesia in Minimally Invasive Mitral Valve Surgery Performed via Right Anterior Mini-Thoracotomy

OBJECTIVE

This study investigated if the serratus anterior plane block (SAPB) within a multimodal analgesia scheme would reduce acute post-operative pain and intravenous opioid consumption in patients admitted to the intensive care unit after isolated minimally invasive mitral valve surgery.

DESIGN

Retrospective study.

SETTING

Patients were admitted to the intensive care unit (ICU) of the University Hospital of Siena (Italy).

INTERVENTIONS

Patients treated with intravenous opioids (OP-G) as a postoperative analgesic regimen were compared to those managed with an opioid-sparing protocol consisting of a single-shot SAPB with 0.5% ropivacaine plus 4 mg dexamethasone administered 1 hour before the extubation (SAPB-G). The behavioral pain scale (BPS) for intubated (I) or non-intubated patients (NI) and the Richmond Agitation Sedation Scale (RASS) scores were collected at ICU admission and every 8 hours during the initial 24 postoperative hours.

MEASUREMENTS AND MAIN RESULTS

One hundred five patients (50 SAPB-G; 55 OP-G) were enrolled (median age 67 [60-70]; male 67 [64%]). RASS score at 8 hours after ICU admission was higher in the SAPB-G (0 [0, 0] v OP-G -2 [-3, 0], p < 0.001). At 24 hours after ICU admission, the number of patients with a BPS/BPS-NI score >4 was lower in the SAPB-G (4.0% v 18.2% OP-G, p = 0.048). SAPB-G received a lower number of opioid rescue doses during the first 24 hours (20% v 84% OP-G, p < 0.001).

CONCLUSIONS

The SAPB may be effective in reducing the postoperative use of opioids in patients undergoing minimally invasive mitral valve surgery. Prospective randomized studies are warranted.

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

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

Demographic and clinical predictors of post-operative atrial fibrillation in cardio-surgical patients

AIMS

Post-operative atrial fibrillation is defined as an episode of atrial fibrillation that occurs 1-5 days after a surgical procedure in patients without a previous history of atrial fibrillation. Multiple factors such as demographics, cardiac surgical, endogenous, or mental health may relate to post-operative atrial fibrillation.The aim of this study was to identify multivariable high-risk factors for post-operative atrial fibrillation and to propose a risk-assessment tool.

METHODS AND RESULTS

A cross-sectional observational study was conducted in a University Hospital of Greece. Predictor variables examined demographic and clinical variables, anxiety, depression, health-related quality of life, frailty, perioperative mortality (European System for Cardiac Operative Risk Evaluation II), and 10-year survival/mortality risk (Charlson Comorbidity Index score). The outcome variable was post-operative atrial fibrillation. Multivariable analysis was assessed to identify predictors of post-operative atrial fibrillation.Ninety-one patients were included in our sample. Post-operative atrial fibrillation was diagnosed in 44 (48.4%). Factors associated with post-operative atrial fibrillation are the following: age group of 66-75 years [OR 5.78, 95% confidence interval (CI) 1.37-24.34], Charlson Comorbidity Index score (OR 1.42, 95% CI 1.07-1.89), and hours of mechanical ventilation (OR 1.03, 95% CI 1.00-1.06). The Charlson Comorbidity Index score was identified as an independent predictor of post-operative atrial fibrillation (exp: 1.412, 95% CI: 1.017-1.961).

CONCLUSION

Patients with post-operative atrial fibrillation had a higher Charlson Comorbidity Index score. The Charlson Comorbidity Index was identified as an independent clinical predictor of post-operative atrial fibrillation. The risk-assessment tool proposed includes age, Charlson Comorbidity Index score, and hours of mechanical ventilation. Future studies are needed to establish such an assessment.

A 3-hour fast-track extubation protocol for early extubation after cardiac surgery

Objectives

Early extubation after cardiac surgery improves outcomes and reduces cost. We investigated the effect of a multidisciplinary 3-hour fast-track protocol on extubation, intensive care unit length of stay time, and reintubation rate after a wide range of cardiac surgical procedures.

Methods

We performed an observational study of 472 adult patients undergoing cardiac surgery at a large academic institution. A multidisciplinary 3-hour fast-track protocol was applied to a wide range of cardiac procedures. Data were collected 4 months before and 6 months after protocol implementation. Cox regression model assessed factors associated with extubation time and intensive care unit length of stay.

Results

A total of 217 patients preprotocol implementation and 255 patients postprotocol implementation were included. Baseline characteristics were similar except for the median procedure time and dexmedetomidine use. The median extubation time was reduced by 44% (4:43 hours vs 3:08 hours; P < .001) in the postprotocol group. Extubation within 3 hours was achieved in 49.4% of patients in the postprotocol group compared with 25.8% patients in the preprotocol group; P < .001. There was no statistically significant difference in the intensive care unit length of stay after controlling for other factors. Early extubation was associated with only 1 patient requiring reintubation in the postprotocol group.

Conclusions

The multidisciplinary 3-hour fast-track extubation protocol is a safe and effective tool to further reduce the duration of mechanical ventilation after a wide range of cardiac surgical procedures. The protocol implementation did not decrease the intensive care unit length of stay.

Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative

Objective

Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure.

Results

We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).

Perioperative care in cardiac surgery

As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.

Early Extubation in Enhanced Recovery from Cardiac Surgery

Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.