Cardiac Surgical Bleeding, Transfusion, and Quality Metrics: Joint Consensus Statement by the Enhanced Recovery After Surgery Cardiac Society and Society for the Advancement of Patient Blood Management.

BACKGROUND: Excessive perioperative bleeding is associated with major complications in cardiac surgery, resulting in increased morbidity, mortality, and cost. METHODS: An international expert panel was convened to develop consensus statements on the control of bleeding and management of transfusion and to suggest key quality metrics for cardiac surgical bleeding. The panel reviewed relevant literature from the previous 10 years and used a modified RAND Delphi methodology to achieve consensus. RESULTS: The panel developed 30 consensus statements in 8 categories, including prioritizing control of bleeding, prechest closure checklists, and the need for additional quality indicators beyond reexploration rate, such as time to reexploration. Consensus was also reached on the need for a universal definition of excessive bleeding, the use of antifibrinolytics, optimal cessation of antithrombotic agents, and preoperative risk scoring based on patient and procedural factors to identify those at greatest risk of excessive bleeding. Furthermore, an objective bleeding scale is needed based on the volume and rapidity of blood loss accompanied by viscoelastic management algorithms and standardized, patient-centered blood management strategies reflecting an interdisciplinary approach to quality improvement. CONCLUSIONS: Prioritizing the timely control and management of bleeding is essential to improving patient outcomes in cardiac surgery. To this end, a cardiac surgical bleeding quality metric that is more comprehensive than reexploration rate alone is needed. Similarly, interdisciplinary quality initiatives that seek to implement enhanced quality indicators will likely lead to improved patient care and outcomes.

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS).

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Temporary Mechanical Circulatory Support after Cardiac Surgery.

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.

The effect of a selenium-based anti-inflammatory strategy on postoperative functional recovery in high-risk cardiac surgery patients - A nested sub-study of the sustain CSX trial.

AIM: The cardiac surgery-related ischemia-reperfusion-related oxidative stress triggers the release of cytotoxic reactive oxygen and nitrogen species, contributing to organ failure and ultimately influencing patients' short- and long-term outcomes. Selenium is an essential co-factor for various antioxidant enzymes, thereby contributing to the patients' endogenous antioxidant and anti-inflammatory defense mechanisms. Given these selenium's pleiotropic functions, we investigated the effect of a high-dose selenium-based anti-inflammatory perioperative strategy on functional recovery after cardiac surgery. MATERIALS AND METHODS: This prospective study constituted a nested sub-study of the SUSTAIN CSX trial, a double-blinded, randomized, placebo-controlled multicenter trial to investigate the impact of high-dose selenium supplementation on high-risk cardiac surgery patients' postoperative recovery. Functional recovery was assessed by 6-min walk distance, Short Form-36 (SF-36) and Barthel Index questionnaires. KEY FINDINGS: 174 patients were included in this sub-study. The mean age (SD) was 67.3 (8.9) years, and 78.7 % of the patients were male. The mean (SD) predicted 30-day mortality by the European System for Cardiac Operative Risk Evaluation II score was 12.6 % (9.4 %). There was no difference at hospital discharge and after three months in the 6-min walk distance between the selenium and placebo groups (131 m [IQR: not performed - 269] vs. 160 m [IQR: not performed - 252], p = 0.80 and 400 m [IQR: 299-461] vs. 375 m [IQR: 65-441], p = 0.48). The SF-36 and Barthel Index assessments also revealed no clinically meaningful differences between the selenium and placebo groups. SIGNIFICANCE: A perioperative anti-inflammatory strategy with high-dose selenium supplementation did not improve functional recovery in high-risk cardiac surgery patients.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023.

Background: Postoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery. Methods: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type. Results: Preoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery. Conclusions: Despite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023.

OBJECTIVES: Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery. METHODS: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS: Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSIONS: Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

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.

Update on minimally invasive cardiac surgery and enhanced recovery after surgery.

PURPOSE OF REVIEW: Numerous recent trials have examined the potential benefits of treating cardiac surgery patients with a minimally invasive approach. Recently, Enhanced Recovery After Surgery (ERAS) has also been applied to cardiac surgery, and specifically to minimally invasive cardiac surgery (MICS) patients. This review will explore current evidence regarding MICS, as well as the combination of MICS plus ERAS. RECENT FINDINGS: Multiple contemporary prospective and retrospective trials have published data demonstrating equivalent or better outcomes with reduced length of stay (LOS) for MICS patients compared to patients undergoing full sternotomy. In fact, recent reviews and met-analyses suggest that MICS is associated with reduced atrial fibrillation, wound complications, blood transfusion, LOS, and potentially cost. Additionally, several new trials reporting longer term follow-up on MICS coronary and valve surgery have demonstrated durable results. Emerging literature on the benefits of combining MICS and ERAS perioperative protocols have also reported promising results regarding reduced LOS and faster recovery. SUMMARY: Minimally invasive cardiac surgery appears to provide patients with equivalent or better outcomes, faster recovery, and less surgical trauma compared to full sternotomy. The addition of ERAS phase specific perioperative protocols can help maximize the benefits of MICS.

Perioperative hemodynamic monitoring in cardiac surgery.

PURPOSE OF REVIEW: Cardiac surgery has traditionally relied upon invasive hemodynamic monitoring, including regular use of pulmonary artery catheters. More recently, there has been advancement in our understanding as well as broader adoption of less invasive alternatives. This review serves as an outline of the key perioperative hemodynamic monitoring options for cardiac surgery. RECENT FINDINGS: Recent study has revealed that the use of invasive monitoring such as pulmonary artery catheters or transesophageal echocardiography in low-risk patients undergoing low-risk cardiac surgery is of questionable benefit. Lesser invasive approaches such a pulse contour analysis or ultrasound may provide a useful alternative to assess patient hemodynamics and guide resuscitation therapy. A number of recent studies have been published to support broader indication for these evolving technologies. SUMMARY: More selective use of indwelling catheters for cardiac surgery has coincided with greater application of less invasive alternatives. Understanding the advantages and limitations of each tool allows the bedside clinician to identify which hemodynamic monitoring modality is most suitable for which patient.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery.

PURPOSE OF REVIEW: This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS: Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY: Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Dexmedetomidine improves pulmonary outcomes in thoracic surgery under one-lung ventilation: A meta-analysis.

INTRODUCTION: Dexmedetomidine improves intrapulmonary shunt in thoracic surgery and minimizes inflammatory response during one-lung ventilation (OLV). However, it is unclear whether such benefits translate into less postoperative pulmonary complications (PPCs). Our objective was to determine the impact of dexmedetomidine on the incidence of PPCs after thoracic surgery. METHODS: Major databases were used to identify randomized trials that compared dexmedetomidine versus placebo during thoracic surgery in terms of PPCs. Our primary outcome was atelectasis within 7 days after surgery. Other specific PPCs included hypoxemia, pneumonia, and acute respiratory distress syndrome (ARDS). Secondary outcome included intraoperative respiratory mechanics (respiratory compliance [Cdyn]) and postoperative lung function (forced expiratory volume [FEV1]). Random effects models were used to estimate odds ratios (OR). RESULTS: Twelve randomized trials, including 365 patients in the dexmedetomidine group and 359 in the placebo group, were analyzed in this meta-analysis. Patients in the dexmedetomidine group were less likely to develop postoperative atelectasis (2.3% vs 6.8%, OR 0.42, 95%CI 0.18-0.95, P = 0.04; low certainty) and hypoxemia (3.4% vs 11.7%, OR 0.26, 95%CI 0.10-0.68, P = 0.01; moderate certainty) compared to the placebo group. The incidence of postoperative pneumonia (3.2% vs 5.8%, OR 0.57, 95%CI 0.25-1.26, P = 0.17; moderate certainty) or ARDS (0.9% vs 3.5%, OR 0.39, 95%CI 0.07-2.08, P = 0.27; moderate certainty) was comparable between groups. Both intraoperative Cdyn and postoperative FEV1 were higher among patients that received dexmedetomidine with a mean difference of 4.42 mL/cmH2O (95%CI 3.13-5.72) and 0.27 L (95%CI 0.12-0.41), respectively. CONCLUSION: Dexmedetomidine administration during thoracic surgery may potentially reduce the risk of postoperative atelectasis and hypoxemia. However, current evidence is insufficient to demonstrate an effect on pneumonia or ARDS.

ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023.

OBJECTIVES: There are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients. METHODS: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type. RESULTS: Preoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. CONCLUSIONS: The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM.

Performance Comparison of Pulmonary Risk Scoring Systems in Lung Resection.

OBJECTIVE: To validate and compare the performance of different pulmonary risk scoring systems to predict postoperative pulmonary complications (PPCs) in lung resection surgery. DESIGN: Retrospective cohort study SETTING: A historic single-center cohort of lung resection surgeries PARTICIPANTS: Adult patients undergoing lung resection surgery under 1-lung ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The accuracy of the following pulmonary risk scoring systems were used to predict pulmonary complications: the ARISCAT (Assess respiratory RIsk in Surgical patients in CATalonia), the LAS VEGAS (Local Assessment of VEntilatory management during General Anesthesia for Surgery), the SPORC (Score for Prediction of Postoperative Respiratory Complications), and a recent thoracic-specific risk score, named CARDOT. Discrimination and calibration were assessed using the concordance (c) index and the intercept of LOESS (locally estimated scatterplot)-smoothed curves, respectively. Additional models were constructed that incorporated predicted postoperative forced expiratory volume (ppoFEV1) into each scoring system. Of the 2,104 patients undergoing lung surgery, 123 developed postoperative pulmonary complications (PPCs; 5.9%). All scoring systems had poor discriminatory power to predict PPCs (ARISCAT c-index 0.60, 95% confidence interval [CI] 0.55-0.65; LAS VEGAS c-index 0.68, 95% CI 0.63-0.73; SPORC c-index 0.63, 95% CI 0.59-0.68; CARDOT c-index 0.64, 95% CI 0.58-0.70), but the inclusion of ppoFEV1 slightly improved the performance of LAS VEGAS (c-index 0.70, 95% CI 0.66-0.75) and CARDOT (c-index 0.68, 95% CI 0.62-0.73). Analysis of calibration showed a slight overestimation when using ARISCAT (intercept -0.28) and LAS VEGAS (intercept -0.27). CONCLUSIONS: None of the scoring systems appeared to have adequate discriminatory power to predict PPCs among patients undergoing lung resection. An alternative risk score is necessary to better predict patients at risk of PPCs after thoracic surgery.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.