I’m going to take a stand on something that really gets my blood boiling… health insurance companies. People want to blame physicians for bad outcomes (I’m looking at you NRA supporters that are claiming we, as physicians, need to fix our own lane first). They want to blame hospitals for long wait times, they want […]
ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist
I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!
Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100
The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852.
Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 2016 Jun;30(3):665-70. doi: 10.1053/j.jvca.2016.01.017. Epub 2016 Jan 16.
A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19.
Clinical Trial: The Safety and Efficacy of the Enhanced Recovery After Surgery(ERAS) Applied on Cardiac Surgery With Cardiopulmonary Bypass: a Single Center, Randomized, Controlled Clinical Study. May 2017.
My blog posts:
- Ketamine for intraoperative and postoperative analgesia
- Lidocaine infusions for pain
- Enhanced Recovery After Surgery (ERAS)
- Level 1 (Class of recommendation=Strong Benefit):
- Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
- Perioperative glycemic control is recommended (BS 70-180; [110-150]).
- A care bundle of best practices should be performed to reduce surgical site infection.
- Goal-directed therapy should be performed to reduce postoperative complications.
- A multimodal, opioid-sparing, pain management plan is recommended postoperatively
- Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
- Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
- Post-operative systematic delirium screening is recommended at least once per nursing shift.
- An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
- Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
- Level IIa (Class of recommendation=Moderate Benefit)
- Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
- Rigid sternal fixation can be useful to reduce mediastinal wound complications.
- Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
- Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
- Early extubation strategies after surgery are reasonable to be employed.
- Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
- Chemical thromboprophylaxis can be beneficial following cardiac surgery.
- Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
- Correction of nutritional deficiency, when feasible, can be beneficial.
- Level IIb (Class of recommendation=Weak Benefit)
- A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
- Carbohydrate loading may be considered before surgery.
These 3 items often give people an upset stomach when talking about the future and planning.
My parents were budgeters… not because they enjoyed it, but because they didn’t have the means to be extravagant. I grew up in a two parent working household and that was to make ends meet. I was extremely fortunate that my parents valued my future, and it was evidenced in how they spent and saved their money. Home cooked meals were the norm — until I started in activities that kept me at lessons or practice from the time school recessed until the late evening. I never questioned the sacrifices they made nor the financial understanding of what they were doing. I’ve learned a lot from how they spent their money, and it’s something I want to pass on to my kid(s).
When I look around at people and their spending habits, I’m appalled at what they purchase. Eating meals out every night…. buying tons of clothes/makeup/shoes…. these are just some of the things that just seem to be wasteful to me. Do I do it? Yes, but minimally. Do I think about it every time and wonder if it’s worth it? Absolutely. But, it’s never too late to start a plan or get on track to be financially savvy or responsible.
If you’ve just graduated high school…. here’s a great place to start: What I Wish I’d Known at 18 from Physician on Fire.
Helpful links to tackle:
- The Money Habit
- Retirement Researcher
- Suze Orman
- Bogle Heads
- Personal Capital
- White Coat Investor
- Physician on Fire
- Passive Income MD
- 1500 Days to Freedom
- Top Personal Finance blogs 2018
- Kiplinger top 10 personal finance blogs
- Inc. top personal finance blogs
- Motley Fool top personal finance blogs