New landmark recommendations published for enhanced recovery after cardiac surgery
As in many specialties, how to best standardize care surrounding cardiac surgery has remained one of the most pressing challenges on the path to the continuous improvement of patient outcomes. This concept took a giant leap forward when the Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Society issued its first-ever set of consensus recommendations highlighting 22 graded measures to consider for optimizing the process. In May 2019, Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations were published in JAMA Surgery.
The landmark manuscript, endorsed by the ERAS Society, became one of the journal’s most downloaded pieces ever and was viewed more than 15,000 times in its first 10 days online.
“Addressing variability from patient to patient and physician to physician can help reduce surgical complications,” explains V. Seenu Reddy, M.D., MBA, a HealthTrust Physician Advisor who collaborated on the paper and is listed as an author. Dr. Reddy is also the Surgical Director of the structural heart program at HCA Healthcare’s TriStar Centennial Medical Center in Nashville, Tennessee.
Enhanced recovery strategies aren’t necessarily generated in response to poor outcomes, Dr. Reddy points out, but rather to improve upon already good results.
Like most other areas in surgery, cardiac surgery was opioid-heavy,” Dr. Reddy says. “This enhanced protocol looked at other ways to be more multimodal in terms of the way surgeons handle postoperative pain management, so patients don’t become dependent upon opioids or suffer from their side effects.
ERAS protocols have been linked with up to 50% reductions in overall complications and length of stays compared with conventional perioperative patient management in noncardiac surgery populations, according to the JAMA Surgery paper.
In addition, there may be substantial savings to the health system from standardization and reductions
in complications.
“It’s really the other way around, saying we may be doing a pretty good job but want to enhance recovery after surgery in a multimodal way,” he says. “Surgery is a major undertaking, so how do we streamline and improve it? We looked at the evidence, data and information out there to make each component—preoperative, intraoperative and postoperative—better.”
Key recommendations
In a process that took several years, Dr. Reddy and his collaborators produced the 22 consensus recommendations for optimal perioperative management of cardiac surgery patients after thoroughly reviewing meta-analyses, randomized clinical trials and large nonrandomized studies.
“The beauty is the recommendations aren’t prescriptive—you don’t have to do everything in the document,” Dr. Reddy says. “We’re saying, here are the things that may enhance your patient’s experience before, during and after a surgical procedure. You can decide which ones fit your pattern of care.”
According to Dr. Reddy, some of the most compelling ERAS Cardiac recommendations include:
Preoperative
Carbohydrate loading: A carbohydrate drink two hours before surgery can reduce insulin resistance as it improves postoperative glucose control and promotes the earlier return of gut function. “It helps with hydration, gives the patient an energy boost and benefits intestinal mucosa,” Dr. Reddy explains.
Patient engagement tools: Education and counseling before surgery can include explanations of procedures and goals that may help alleviate fear, fatigue and discomfort, promoting recovery and early discharge. “We should offer better and more robust information to patients before they have surgery,” Dr. Reddy suggests. “In cardiac procedures, we can help reduce the levels of anxiety by giving patients a lot of information about what to expect.” It may also help patients set and work toward realistic recovery goals.
Intraoperative
Surgical site infection reduction: A care bundle that includes topical intranasal therapies to eradicate staphylococcal colonization, skin preparation, depilation protocols and weight-based cephalosporin infusion should be combined with smoking cessation, adequate glycemic control and other measures to cut the chance of surgical site infections.
Postoperative
Pain management: “While opioids were until recently the mainstay analgesic choice after cardiac surgery, a multimodal pain management approach is now vital,” Dr. Reddy says. No single pathway exists for an opioid-sparing approach, but evidence backs the use of acetaminophen, tramadol, dexmedetomidine and pregabalin. Patients should also be counseled preoperatively to establish appropriate expectations for postoperative pain and analgesia use.
Pilot program expanded
Enhanced recovery protocols are sweeping the fields of surgery, Dr. Reddy says. At TriStar Centennial, where about 1,200 cardiac surgeries are performed annually, the lead clinical pharmacist approached Dr. Reddy about three years ago to propose a pilot project in enhanced recovery, and he quickly agreed. The project case-matched about 100 patients, finding many benefits, he says, and officials there are in the process of devising core metrics for a sustained effort.
Nationally, the ERAS Cardiac Society is already looking ahead to examining and developing updated guidelines based on new techniques, newer medications and newer assays that may further improve the patient’s surgical experience. “The great part of ERAS is the continuous quality improvement nature of the undertaking and never being entirely satisfied with your results,” says Dr. Reddy.
So, what’s next? Dr. Reddy says that becoming the “next ERAS Cardiac Center of Excellence” is a high priority for TriStar Centennial Medical Center.
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