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

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in noncardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results. METHODS: We retrospectively analyzed 73 consecutive patients treated with ERAS care compared with 74 patients treated before implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization. RESULTS: ERAS patients required significantly less opioids captured as total morphine milligram equivalents (MME) (median 35.0 vs 75.3; P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 vs 0.5; P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (postoperative day 4: 95% vs 81%; P = .013) and postoperative length of stay was lower for ERAS care but did not reach statistical significance (median 4 days vs 5 days; P = .06). There was no difference in pain or glucose control or in early extubation. CONCLUSIONS: Cardiac ERAS significantly decreased opioid use, nausea, and lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital.

Postoperative Multimodal Analgesia in Cardiac Surgery.

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

N-acetylcysteine and fenoldopam protect the renal function of patients with chronic renal insufficiency undergoing cardiac surgery.

OBJECTIVE: To determine whether fenoldopam and N-acetylcysteine prevent renal deterioration and improve hospital outcome for patients with chronic renal insufficiency undergoing cardiac surgery. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: A community hospital that is a cardiac referral center. PATIENTS: Seventy-nine adult patients with chronic renal insufficiency (creatinine clearance < or = 40 mL/min) who underwent cardiac surgery. INTERVENTIONS: Group 1 received intravenous fenoldopam 0.1 microg/kg/min started at surgical induction and continued for 48 hrs. Group 2 received N-acetylcysteine 600 mg orally twice a day, from preoperative day 1 to postoperative day 1. Group 3 received both fenoldopam and N-acetylcysteine, and group 4 patients served as controls. MEASUREMENTS AND MAIN RESULTS: Using multiple comparisons (analysis of variance) with change scores, and statistically adjusting for group differences in aortic cross-clamp time, use of intraoperative aprotinin, and preoperative use of statin, we found that the change in creatinine clearance from preoperative to postoperative day 3 was statistically less for group 1 (-1.47 mL/min +/- 2.06 SE, p = .0286) and for group 2 (-0.67 mL/min +/- 2.11 SE, p = .0198) and less but not quite significant for group 3 (-3.08 mL/min +/- 1.95 SE, p = .0891) compared with controls (-8.15 mL/min +/- 2.18 SE). Furthermore, the adjusted weight gain on postoperative day 3 was 5.55 kg +/- 1.00 SE (p = .0988) for group 1, 5.06 kg +/- 1.06 SE (p = .0631) for group 2, and 5.14 kg +/- .91 SE (p = .0445) for group 3 compared with 8.03 kg +/- 1.07 SE for group 4. However, there was no decrease in length of critical care or hospital stay or hospital costs. Finally, fenoldopam contributed to perioperative hypotension. CONCLUSIONS: Perioperative fenoldopam and N-acetylcysteine abrogate the early postoperative decline in renal function of patients who have chronic renal insufficiency, although these agents do not affect other parameters of cardiac surgical outcome.