Aggregation of marginal gains in cardiac surgery – feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients

• Published in: Journal of cardiothoracic and vascular anesthesia 2016-06, Vol.30 (3), p.665-670
• Main Authors: Fleming, Ian O, Garratt, Claire, Guha, Ranj, Desai, Jatin, Chaubey, Sanjay, Wang, Yanzhong, Leonard, Sara, Kunst, Gudrun
• Format: Article
• Language: English
• Subjects: Aged; Anesthesia & Perioperative Care; cardiac surgery; Cardiac Surgical Procedures; Critical Care; enhanced recovery; Feasibility Studies; Female; Humans; Length of Stay; Male; Middle Aged; Pain, Postoperative - physiopathology; Perioperative Care; perioperative quality improvement bundles; Pilot Projects; postoperative morbidity; Prospective Studies; Quality Improvement; Recovery of Function
• ISSN: 1053-0770; 1532-8422
• DOI: 10.1053/j.jvca.2016.01.017

Abstract Objectives The aim of this pilot study was to assess feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS). Design A prospective observational audit. Setting A major urban teaching and university hospital and tertiary referral center. Participants Patients undergoing cardiac surgery: 53 patients studied before implementation of ERACS (pre-ERACS group) and 52 patients after (ERACS group). Interventions Based on recommendations from a consensus review in colorectal surgery, the following enhanced recovery perioperative care bundle was applied: detailed preoperative information, avoidance of prolonged fasting periods preoperatively, preoperative carbohydrate beverages, optimization of analgesia with avoidance of long-acting opioids, prevention of postoperative nausea and vomiting, early enteral nutrition postoperatively, and early mobilization. Measurements and Main Results We hypothesized that length of hospital stay would be reduced with ERACS. Secondary outcome variables included a composite of postoperative complications and pain scores. Whereas the length of stay in the group of patients receiving the bundle of enhanced recovery interventions remained unchanged compared to the non-ERACS group, there was a statistically significant reduction in the number of patients in the ERACS group presenting with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, postoperative myocardial infarction and death). Additionally, postoperative pain scores were significantly improved in the ERACS group. Conclusions This pilot study demonstrates that ERACS is feasible and has the potential for improved postoperative morbidity after cardiac surgery. A larger multi-center quality improvement study implementing perioperative care bundles would be the next step to further assess outcomes in ERACS patients.