ERAS for Cardiac Surgery

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!

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

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

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

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. 

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

ERAS
From Journal of Anesthesiology

Enhanced Recovery After Cardiac Surgery Society

My blog posts:

Key Points

  • 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.

 

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

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Esophagectomy

The case is booked as an Ivor-Lewis esophagectomy.  Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.

What’s an Ivor-Lewis esophagectomy?

Esophagectomy

Anesthetic monitors:

  • Central line (Cordis for volume in emergency)
  • Vigileo/FloTrac – SVI, SVV, SVR, CO great markers for fluid management
  • BIS
  • UOP

Anesthetic technique:

  • Induction: lidocaine, Propofol, rocuronium/sux (dependent upon if blockage from tumor necessitating RSI or not)
  • Maintenance: sevoflurane
  • Extubation: attempt in OR
  • Fluid management
    • Colloid vs. crystalloid
    • CVP vs. Esophageal doppler vs. pulse pressure vs. stroke volume variation
      • Keep SVI >35 mL/m2 to decrease risk of AKI
  • OLV
    • To reduce lung damage and ARDS
    • 4-6 cc/kg ventilation strategy (lung-protective)
    • Pressure-controlled
    • Optimization of PEEP
    • PIPs <35mmHg, Plateau pressure <25mmHg
  • Pain Management
    • Pre-op adjuvant pain meds:
      • Oxycodone XR 20mg PO if <70y/o or 10mg if >70yo
      • Celecoxib 400mg PO if <70y/o or 200mg if >70yo
      • Pregabalin 150mg PO if <70y/o or 75mg if >70yo
    • Thoracic Epidural: Improved blood flow to anastomotic site, earlier extubation times, reduced pneumonia rates.
  • Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.

Case:

40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior.  Presented to ED with N/V, epigastric pain, malnourishment.  Had underone chemo and radiation.  PMH achalasia, endometriosis.  NKDA. Scheduled for Ivor-Lewis esophagectomy.  Pt appeared cachectic, on TPN, 45kg, 5’5″.  L chest port-a-cath in place.

In OR, pt received T7 epidural.  RSI w cricoid pressure throughout.  37Fr L DLT placed gently without resistance.  31cm at teeth noted after fiberoptic bronch check.  20g L radial a-line placed.  Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP.  FloTrac for SVI, SVR, SVV, CO.

Albumin for IVF.  Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90.  OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor).  BIS goal 40-60.  Epidural initially dosed with 5ml 2% lido with epi.  Another dose given roughly 30 minutes later.  Remaining dosing throughout case with 4ml 0.25% bupi.  Acetaminophen IV 1000mg prior to incision.  Fentanyl IV for abdominal laparoscopy.

Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy.  Converted to laparotomy.  Tumor adhered to pericardium.

R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg).  Good lung isolation.  Good anastamosis of tissues.  Two lung ventilation according to surgeon.  Recruit lungs to decrease atelectasis.

Emergence: + Pressure support through DLT.  Extubate in OR.

Lessons learned:

  1. Early communication with surgeon(s).
  2. Lung-protective strategies
  3. Volume restriction for IVF
  4. Appropriate pressor choice
  5. Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above.  If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon).  Continue baseline pain regimen if patient is a chronic pain patient.
  6. Setup is key.  Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.

Resources:

 

Anesthesia and Breastfeeding

I get a lot of questions from my friends about receiving anesthesia while breastfeeding.  As more moms are breastfeeding, I think it’s an important question to tackle for the baby’s safety.  I’ve included references and summarized key points below.  If you have any questions, please do not hesitate to ask your anesthesiologist or physician who will be taking care of you.

 

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From Anesthesiology, October 2017.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.  Transl Perioper Pain Med. 2015; 1(2): 1–7.

ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017.  BREASTFEEDING MEDICINE Volume 12, Number 9, 2017.

KellyMom: breastfeeding and surgery resources

Key Points:

  • Intrathecal and epidural anesthesia and opioids are ok for breastfeeding mothers.
  • Acetaminophen, ibuprofen, and ketorolac are ok because they have relatively short half-lives.
  • Celecoxib: ok.
  • Naproxen: ok.
  • Propofol is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Midazolam (sedation dose) is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Fentanyl is short-acting enough.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Avoid meperidine in the post-operative unit – its metabolites have long half-lives.
  • Hydromorphone has a long half-life (10hours).  Best to avoid this medication or pump and dump.
  • Morphine: low dose is ok.  Caution if using morphine PCA.
  • Hydrocodone: dosage should be <30mg/day in breastfeeding moms.
  • Oxycodone: dosage should be <30mg/day in breastfeeding moms or not used at all.
  • Tramadol: ok. But FDA not recommend for breastfeeding moms (USA).

Things to Consider

  • Try to have your case booked as early in the morning to decrease the amount of time for fasting.
  • Pump a stash of breast milk ahead of surgery for 1 day of feeds just in case.  You can always use this expressed milk later.
  • Breastfeed or express milk just before the start of the procedure.
  • Have an adult supervise you post-operatively as well as the baby in case there are signs of medication transferred to the baby.
  • Consider anesthetic techniques (local anesthesia, regional anesthesia, non-narcotics, etc.) to minimize opioid consumption.

 

 

Ketamine for intraoperative and postoperative analgesia

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

ketamine_hydrochloride_050

Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017:
    • Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved.  Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol.  Patients are more comfortable and require less pain medication.
  • Dec 2018:
    • Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming; infusion 0.2 mg/kg/hr stopping when last dressing placed.

 

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Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY. NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial. HSS Journal: Volume 4, Number 1.

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review. BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

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Acute and Chronic Post-Thoracotomy Pain, modes of treatment

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.


***UPDATE July 8, 2018 ***

AnesthesiologyNews: July 2018: New Consensus Guidelines Issued for Use of IV Ketamine for Acute Pain.

  • Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
    Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
  • Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
    Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
  • Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
    Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
  • Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
    Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
  • Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
    Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
  • Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
    Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.

New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).

The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.


Update Nov, 30, 2018

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 456–466

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.  Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 521–546

Methadone and acute and chronic pain management

We had a journal club where we discussed this article: Anesthesiology, May 2017; Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery: a randomized, double-blinded, controlled trial.

  • IV Methadone 0.2 mg/kg vs IV hydromorphone 2mg at surgical closure in 2+ level spinal fusion
  • Decreased postop IV and opioid requirements and pain scores.  Improved patient satisfaction

Questions:

  1. Is there a pain service following these patients postoperatively?
  2. Exclusions: do you include OSA and BMI>45 patients?
  3. Is ETCO2 and PCA enough to combat respiratory depression on the floor?
  4. Are any discharged on the same day after receiving this dose — think total knees and single level lamis?
  5. Will this improve or worsen the opioid epidemic?
  6. Are surgeons on board with tackling pain multimodally for the benefit of the patient?
  7. For pain follow-up, are there psychiatry, homeopathy, palliative care, PT, holistic approaches for the patient?

 

Methadone Dose Conversion Guidelines

Intraop Lidocaine for postop pain

Intraop Ketamine for postop pain

 

Literature search:

Sys Rev 2014: Effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment protocol.

Am j of Pub Health, Aug 2014. Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review.

Br J Clin Pharmacol. 2014 Feb; 77(2): 272–284. Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

PLoS One. 2014; 9(11): e112328. Methadone Induction in Primary Care for Opioid Dependence: A Pragmatic Randomized Trial (ANRS Methaville).

Curr Psychiatry Rev. 2014 May; 10(2): 156–167. Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence. 

Drug Alcohol Depend. 2016 Mar 1; 160: 112–118. Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis. 

Croat Med J. 2013 Feb; 54(1): 42–48. Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia. 

J Med Toxicol. 2016 Mar; 12(1): 58–63. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”. 

Syst Rev. 2014; 3: 45. Sex differences in outcomes of methadone maintenance treatment for opioid addiction: a systematic review protocol.