Controversies in enhanced recovery after cardiac surgery

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery

PURPOSE OF REVIEW

This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery.

RECENT FINDINGS

Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing.

SUMMARY

Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience

OBJECTIVES

Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution.

DESIGN

A retrospective cohort study.

SETTING

This study was a single-institution study conducted at a university hospital.

PARTICIPANTS

Patients undergoing open adult cardiac surgery.

INTERVENTIONS

Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented.

MEASUREMENTS AND MAIN RESULTS

A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts.

CONCLUSIONS

Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.