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

Lidocaine infusions for pain

From Anesthesiology 2017

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

30tt01

Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From Jama Surgery 2017

 

Here’s what I’m currently using:

  • October 2017
    • Lidocaine bolus: 1.5mg/kg on induction
    • Infusion: 2-3mg/kg/hr after induction to end surgery
    • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.

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.

Annoyances

A Carlens double-lumen endotracheal tube, used...
Image via Wikipedia

Lately, I’ve been annoyed by the things going on at work. I’m not even sure why I’m annoyed. Here’s an email conversation (in order from top to bottom) of a recent annoyance (names have obviously been changed)….things noted in italics are particularly annoying to me:

Dr. QA: “Hello esteemed colleagues, I received a QA regarding a patient of Surgeon for thoracotomy who became unresponsive and required reintubation. Please provide me with any details you may have regarding the incident. Thank, QA”

Attending: “Hi Team, Do you what to explain to Dr. QA what happened. He is on our side. I would also stress that Resident is the one who discovered the patent and initiated the treatment. Please Cc me on the e-mail. Thanks, Attending”

Attending to Dr. QA: “Hi QA, I have asked our fellow and RESIDENT to write you a detailed summary of what happened, as fellow was there during extubation and resident was there during re-intubation. Instead of he said, she said its best to hear it from them. We had a debriefing about the incident and we feel it was a combination of several factors. I fully support their summary. Thanks,”

My account: “Hi Attending and RESIDENT, I’m going to cover the elements of induction, intraop events, and extubation. RESIDENT, would you mind discussing the details of finding the patient “obtunded” and the re-intubation?

fellow:
I met with Dr. Surgeon in the pre-op area prior to surgery to discuss R VATs and likelihood for converting to an open thoracotomy. He was pretty adament that the surgical procedure could proceed as a VATs with very low likelihood for conversion. I asked if he would like for the patient to have an epidural just in case the case converted, however, he declined an epidural for her at that time. Therefore, we opted NOT to proceed with a thoracic epidural for post-op pain. Prior to induction, the patient was quite hypertensive (SBP ranging 170s-200s, preop SBP 155). Intraoperatively, she received roughly 250mcg fentanyl on induction. She had a history of a L paralyzed vocal cord, however I believe the vocal cords were open bilaterally according to the resident on direct laryngoscopy. A 35Fr L DLT was placed without noticeable trauma or difficulty. The DLT placement was confirmed with fiberoptic bronchoscopy and OLV was provided for the least time possible that was needed by the surgeon (bronchial cuff was deflated as soon as was deemed possible for surgical visualization). 3mg morphine was given at the beginning of the case. Throughout the case, she was given a couple of extra boluses of fentanyl and morphine (please see anesthesia record for exact amounts). At the end of the case, I spoke with Dr. Surgeon and he agreed to place intercostal nerve blocks for the open thoracotomy incision. The patient was breathing spontaneously through her DLT at skin closure (she had 4 full twitches and was given half dose reversal of glyco/neostigmine). As I recall, her tidal volumes through the DLT were in the 300s at PS 12 and RR 16-23 on 100%FiO2 with a SaO2 100%. At this time, I felt that she was adequately ventilating through a 35 L DLT, and she was grimacing from pain. We suctioned her oropharynx prior to extubating her to a FM 10L O2, and she remained stable in her breathing pattern. She was able to follow commands and generate some mild coughing. She was not stridorous or having any increased work of breathing. She had good chest excursion during spontaneous respiration. I believe she did receive some narcotic at this time while still in the OR. Additionally, we felt that she had adequate narcotics for her pain even though she was hypertensive (SBP 170s-190s similar to pre-induction)..therefore, we treated her hypertension with boluses of labetalol that improved her SPB to 150s (pre-op level). We were there roughly 5-10 minutes after the narcotic as we needed to transition the patient from the OR bed to the PACU bed. She was still following commands and breathing adequately on FM. We arrived to the PACU and checked in with the PACU nurse. She appeared to grimace still from discomfort, and I believe the resident administered some fentanyl (again, please see anesthesia record for details). At this time, I walked to the anesthesia workroom to grab an epidural kit for post-op pain and walked back to the PACU (roughly 5-10min). When I got back to the PACU, the patient appeared comfortable and had a RR of 8 on monitor). She did arouse to name and gentle push. I asked the PACU nurse if he was comfortable caring for her and we let her know that she did have a paralyzed vocal cord, therefore her airway may need closer attention. At that time, I felt her BP and pain control were under better control and she was arousable by name and gentle nudging.

Dr. RESIDENT will be able to give his account as he found her in the PACU.”

(notice how i didn’t throw resident under the bus?)

RESIDENT’S account: “Hi, The events of the case as described by [fellow] are all accurate. My account will begin with extubation and follow through the PACU course. Just prior to extubation, 3mg Morphine was administerred as RR was in the mid 20’s. After this dose, RR decreased to the range described by [fellow]. As noted below, the pt was extubated in the OR to face mask. At that time she was responsive, and her breathing was un-labored. En-route to PACU, pt began to experience significant pain from the surgical site. Upon arrival in the PACU, 50mcg fentanyl was administerred. She was then connected to all standard PACU monitors, and report was given to the PACU RN. [fellow] got an epidural tray from the work room with plans for a thoracic epidural once the pt was more settled in PACU. Approx 10 minutes had passed, and although the pts pain was improved, she was still experiencing discomfort. At that time, an additional 50mcg fentanyl was administerred. I then proceeded to enter my PACU orders on the computer. After that, I returned to the bedside to check on the pt one last time prior to leaving the PACU. Upon arrival at the bedside, I noticed the pulse-ox alarming and reading a value in the mid 70’s. I called the pts name to which she did not respond. I then proceeded to tap the pt on the shoulder, followed by sternal rub. She did not respond to either stimulus. At this time O2 sat was 70%, and the pt was noted to be cyanotic. I called for an ambu bag which the nurse at the adjascent bed provided very quickly. I initiated bag mask ventilation. I was able to move air, though stridor was noted with each breath. The pt was notably more difficult to mask ventilate than she had been on induction of anesthesia in the OR. An oral airway was placed, and mask ventilation continued, though there continued to be marked stridor. O2 sats had returned to high 90’s-100%. At that time 2 CRNA’s and a CA-1 arrived with the code bag. 2-person mask ventilation was intiated while re-intubation supplies were prepared. 1.5mg Midazolam and 100mg propofol were administerred. No muscle relaxant was given. I performed a DL which yielded a grade 1 view. The vocal cords were noted to be midline and tightly opposed except for a small area inferiorly. At that time I asked for a 6.0 ETT, though I was able to pass the 7.0 ETT which had been prepared without significant difficulty. Shortly after intubation while still ventilating by Mapleson prior to RT arriving with a vent, the pt did begin to resume spontaneous ventilation. After being placed on the Vent. 8mg Decadron was given due to concern for possible airway edema. A propofol gtt was started for sedation. The pt was taken to the ICU where she was maintained on scheduled Decadron. Please refer to the chart for further ICU course details. On POD#1, bronchoscopy was performed, which did not reveal any significant airway edema. After confirming an air-leak around the deflated cuff of the ETT, the pt was extubated.

Please let me know if I can provide any further information. Thanks.”

(why on earth would you stack 100 mcg fentanyl on an 80 year old in the PACU who just had a thoracotomy?  Blood pressure was being controlled with labetalol… pain is the 5th vital sign, right?  in someone who has a fragile airway, don’t completely eliminate the pain and sacrifice the airway.  Loss of the airway will KILL someone…. pain doesn’t KILL.)


ATTENDING email to QA: “Hi Dr. QA, As you can see very detailed information about the case. Fellow and Resident did an outstanding Job taking care of this patient. Given her age, VC paralysis, double lumen tube( 35F) together with narctics might have lead to this incident.
The other thing, if it wasn’t for Resident going back to check on patient, we would have been called few minutes later for a full code. I will definitly take this to the PACU nurse manager.
FYI I was present during the start of the case and responded to the PACU page, but by the time I arrived to PACU, Resident already took care of everything.
Thank you CT fellow and Resident!”

Here are my current thoughts:
can you believe this? let’s thank the CA-1… who clearly over-narcotized her (let’s not sugar coat it with a L paralyzed vocal cord and a 35Fr L DLT)… who didn’t know how to give naloxone… who subsequently reintubated her… And let’s shift blame to PACU nurse.  seriously??

New commercial:
Reintubation: $50
Converting PACU to SICU stay: $1000
Knowing how to use naloxone to reverse narcotized patient: priceless
Some things residency doesn’t teach…