New guidelines for cardiac surgery care

Heart patients in the US are set to benefit from an update to the official guidelines for perioperative care to include the ERAS (Enhanced Recovery After Surgery) initiative to promote recovery.

The ERAS protocols were originally initiated in the 1990s by a group of academic surgeons to improve perioperative care for patients receiving colorectal care but have since been developed for multiple surgical specialties.  

They have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management and lead author, Dr Daniel Engelman from the Baystate Heart and Vascular Program, explained that while the ERAS approach showed early promise in cardiac surgery (CS) during trials, evidence-based protocols for CS had not been developed – till now. 

“Although ERAS is relatively new to CS, we anticipate that programs can benefit from these recommendations as they develop protocols to decrease unnecessary variation and improve quality, safety, and value for their patients,” he said. 

“CS involves a large clinician group working in concert throughout all phases of care. Patient and caregiver education and systemwide engagement (facilitated by specialty champions and nurse coordinators) are necessary to implement best practices – this article reports the first expert-consensus review of evidence-based CS ERAS practices. 

“To address the need for evidence-based ERAS protocols, we formed a registered nonprofit organization (ERAS Cardiac Society) to use an evidence-driven process to develop recommendations for pathways to optimize patient care in CS contexts through collaborative discovery, analysis, expert consensus, and best practices.”  

A multidisciplinary group of 16 cardiac surgeons, anaesthesiologists, and intensivists were identified who demonstrated expertise and experience with ERAS. The group agreed on 22 potential interventions, divided into preoperative, intraoperative, and postoperative phases of recovery. 

“We followed the 2011 Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, using a standardized algorithm that included experts, key questions, subject champions, systematic literature reviews, selection and appraisal of evidence quality, and development of clear consensus recommendations,” Dr Engleman said. 

“We minimized repetition of existing guidelines and consensus statements and focused on specific information in the framework of ERAS protocols.” 

While a summary of the new ERAS informed US-based, CS guidelines is listed below, the full document is available here 

Preoperative Strategies: 

  • Preoperative Measurement of Haemoglobin A1c for Risk Stratification 
  • Preoperative Measurement of Albumin for Risk Stratification 
  • Preoperative Correction of Nutritional Deficiency 
  • Consumption of Clear Liquids Before General Anaesthesia 
  • Preoperative Carbohydrate Loading 
  • Patient Engagement Tools 
  • Prehabilitation 
  • Smoking and Hazardous Alcohol Consumption 

Intraoperative Strategies  

  • Surgical Site Infection Reduction  
  • Hyperthermia  
  • Rigid Sternal Fixation 
  • Tranexamic Acid or Epsilon Aminocaproic Acid 

Postoperative Strategies 

  • Perioperative Glycaemic Control 
  • Insulin Infusion 
  • Pain Management 
  • Postoperative Systematic Delirium Screening 
  • Persistent Hypothermia 
  • Chest Tube Patency 
  • Chemical Thromboprophylaxis 
  • Extubating Strategies 
  • Kidney Stress and Acute Kidney Injury 
  • Goal-Directed Fluid Therapy