Rigid Sternal Fixation and Enhanced Recovery for Opioid-free Analgesia After Cardiac Surgery.

BACKGROUND: We evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice. METHODS: This single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent surgery before implementation of RPF or ERP ("Controls"), patients closed with RPF prior to ERP implementation ("RPF-only") and patients managed with RPF and ERP during early "RPF+ERP-2020" and late "RPF+ERP-2022" implementation. RESULTS: Six hundred and eight median sternotomy patients (mean age 65.7 ± 10.8 y; 29.6% female) were included in the analysis. Of those, 59.2% were isolated coronary artery bypass grafting and 7.7% were isolated valve procedures; the remainder were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents in the control cohort versus 0 morphine milligram equivalents for RPF+ERP-2022 (P<.0001) despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls versus 79.6% for RPF-only (P=.010) and 93.5% for RPF+ERP-2022 (P<.0001). Median opioids prescribed at discharge were 600 morphine milligram equivalents for controls versus 0 for RPF+ERP-2020 and RPF+ERP-2022 (P<.0001); 86.7% of RPF-only patients received prescription opioids at discharge versus 5% and 4.3% in RPF+ERP-2020 and RPF+ERP-2022, respectively (P<.0001). These outcomes occurred without increased readmissions. CONCLUSIONS: Systematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population.

Implementing a Preoperative Anemia Optimization Protocol for Cardiovascular Surgery Patients: A Quality Improvement Project.

BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.

Advanced artificial intelligence-guided hemodynamic management within cardiac enhanced recovery after surgery pathways: A multi-institution review.

Objective: The study objective was to report early outcomes of integrating Hypotension Prediction Index-guided hemodynamic management within a cardiac enhanced recovery pathway on total initial ventilation hours and length of stay in the intensive care unit. Methods: A multicenter, historical control, observational analysis of implementation of a hemodynamic management tool within enhanced recovery pathways was conducted by identifying cardiac surgery cases from 3 sites during 2 time periods, August 1 to December 31, 2019 (preprogram), and April 1 to August 31, 2021 (program). Reoperations, emergency (salvage), or cases requiring mechanical assist were excluded. Data were extracted from electronic medical records and chart reviews. Two primary outcome variables were length of stay in the intensive care unit (using Society of Thoracic Surgeons definitions) and acute kidney injury (using modified Kidney Disease Improving Global Outcomes criteria). One secondary outcome variable, total initial ventilation hours, used Society of Thoracic Surgeons definitions. Differences in length of stay in the intensive care unit and total ventilation time were analyzed using Kruskal-Wallis and stepwise multiple linear regression. Acute kidney injury stage used chi-square and stepwise cumulative logistic regression. Results: A total of 1404 cases (795 preprogram; 609 program) were identified. Overall reductions of 6.8 and 4.4 hours in intensive care unit length of stay (P = .08) and ventilation time (P = .03) were found, respectively. No significant association between proportion of patients identified with acute kidney injury by stage and period was found. Conclusions: Adding artificial intelligence-guided hemodynamic management to cardiac enhanced recovery pathways resulted in associated reduced time in the intensive care unit for patients undergoing nonemergency cardiac surgery across institutions in a real-world setting.