ERAS in cardiac surgery - from theory to practice

From the Annual Meeting of the DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie e.V.) on 2 March 2020

The concept of "Enhanced Recovery after Surgery" (ERAS®) is gaining more and more attention in many surgical specialties. The lunch symposium during the 49th DGTHG Annual Meeting in Wiesbaden focused on the measures recommended in the recently published ERAS Cardiac Guidelines and how ERAS® can be implemented in cardiac surgery.

Introducing the ERAS® Cardiac Guidelines

"It's definitely worth thinking about if some complications can be avoided."

Professor Sander, Senior Consultant in Anaesthesia and Intensive Care Medicine at the University Hospital of Giessen, introduced the focus of the symposium by referring to the post-operative complication rate of 1/3 to ¼ globally.

He cited a multicenter trial, published in 2016, in which data from over 44,000 patients from nearly 500 hospitals in 27 countries were analyzed. While 16.8% of all patients suffered one or more post-operative complications, the sub-group of patients who had undergone cardiac surgery had a complication rate of 57%, with the highest risk-adjusted mortality, at 2.3%.{1} "It's definitely worth thinking about if some complications can be avoided," commented Prof. Sander. He emphasized that in the post-operative setting, the risk of experiencing a complication is 1,000 times higher in the first 30 days.

The "Enhanced Recovery After Surgery" (ERAS) concept is something that can help reduce complications and accelerate recovery in a hospital setting. When discussing the success of the concept, which involves using a range of measures before, during and after surgery, Prof. Sander refers to colon surgery. It has been possible to reduce morbidity significantly, by almost 50%.2

Since May 2019, guidelines for cardiac surgery have also been published.3 Based on data from around 200 publications, colleagues recommend a set of measures for perioperative treatment of cardiac surgery patients. Prof. Sander listed all of the relevant measures and then presented the initial results from the field of cardiac surgery: a type of proof-of-principle study4 sought to introduce these measures. The results showed that, after the ERAS protocol was implemented, the duration of treatment in hospital and in intensive care decreased. Gastrointestinal complications reduced by a factor of two. Further studies have been published since, in which small collectives implemented either all of the measures or a selection of them and were able to evidence positive outcomes.

Finally, Prof. Sander noted that there is still a lot to do. One question for future trials will certainly involve establishing which of the measures in the guidelines have the most impact on the patient's outcomes.

Establishing an ERAS® program in cardiac surgery

"The early mobilization of the patients is equally important. This includes extubation while they are still in the operating theatre, breathing exercises and first mobilization in the recovery room. Mobilization sessions follow in the evening and over the next few days."

Prof. Girdauskas, Cardiac Surgeon and Executive Senior Consultant at the Cardiac and Vascular Centre at University Medical Centre Hamburg-Eppendorf (UKE), reported the results of the pilot phase of the ERAS project that was implemented at UKE two years ago.

It all started with an interdisciplinary trip to Sao Paulo, where Prof. Girdauskas and his team (including cardiac anesthetists, physiotherapists and cardiologists) spent a week shadowing the cardiac surgery department at Sancta Maggiore hospital. With an established model and an experienced team, their Brazilian colleagues succeeded in establishing a protocol whereby cardiac surgery patients could be discharged from hospital on the first post-operative day if their condition allows this.

Based on this, they derived measures for the Hamburg model which are consistent with the German DRG (Diagnosis Related Groups) and OPS (Optimization through Primary and Secondary Control) model, says Prof. Girdauskas. They used pre-selection criteria to primarily include healthier patients who had undergone minimally invasive valve surgery in the pilot phase.

Prof. Girdauskas believes that the package of interacting measures is vital to success, with pre, intra and post-operative pillars, as he demonstrated in his presentation. There are two components that Prof. Girdauskas sees as unquestionably important:

  • the interdisciplinary outpatient explanatory conversation
  • the early mobilization of the patient

The interdisciplinary outpatient explanatory conversation (2-3 weeks before the operation) is labor-intensive for the hospital but is very well-received by patients as they feel well supported. The patient learns how the ERAS program works and is shown the differences compared to standard care. Patients receive a flyer with physiotherapy training and are prepared for the breathing exercises. Close involvement of the family in the treatment process should not be underestimated here.

The early mobilization of the patient is equally important, says Prof. Girdauskas. This includes extubation while they are still in the operating theatre, breathing exercises and first mobilization in the recovery room. Mobilization sessions follow in the evening and over the next few days.

Initial data from the pilot phase show that implementing the program can significantly reduce the duration of a patient's stay in the intensive care unit and of hospitalization overall. In this context, Prof. Girdauskas once again referred to the importance of cross-departmental, interdisciplinary cooperation as having a decisive impact on the success of an ERAS concept.

New results are expected in the future as part of a randomized trial on this protocol, which was possible thanks to financial support from a Federal Joint Committee innovation fund. Inter-sectoral cooperation is also seen as important and there is close partnership working with the referral pathway and with post-operative rehab care.

Leipzig Heart Center case study: Post-Anesthesia Care Unit (PACU)

"The concept can only succeed when everyone is on board."

A fast-track concept which includes aspects of the ERAS program has been implemented in Leipzig since 2005, explains Prof. Ender, Senior Consultant in Anesthesia and Intensive Care Medicine at Leipzig Heart Center. Pointing to the results of a Cochrane analysis5, the Leipzig fast-track program, in conjunction with risk stratification, seems to offer a promising way to finally reduce post-operative treatment time without risk to the patients.

Based on this program, patients who have undergone cardiac surgery ideally move from the recovery room to the intermediate care on the same day. Following this they are transferred to the normal ward, without spending time in the ICU (Intensive Care Unit) in most cases.

What started in November 2005 with a recovery room equipped with three beds, is now a fixture with 8 beds in the Heart Center. Internal statistics show that in the first year, just 18% of cardiac surgery patients received post-operative care via this route, while in 2019 the figure was over 52%. This currently corresponds to nearly 20,000 patients. Those who are suitable for the fast-track program are identified using simple targeting criteria and prioritized in the operating schedule.

"It is simply worth thinking about the structures", says Prof. Ender, illustrating this with the data from Leipzig.6 When the patient comes into the intensive care unit, they stay overnight, regardless of whether or not they have been extubated. Some of the reasons for this are logistical.

Data from a follow-up trial also showed promising results.7 The randomized controlled trial confirmed the earlier results and, for fast-track patients, showed a significant reduction in extubation time, ventilation time, duration of stay (PACU vs. ICU) and a lower incidence of arrhythmia.

For Prof. Ender, the differences were mainly due to:

  • adequate staffing, i.e. better staff-to-patient ratio in the recovery room.
  • the possibility to strictly comply with the set protocols.

An evaluation also showed that a 12-hour shift in the recovery room is better than 24 hours, which is why opening hours are limited to 12 hours per day.

And finally, teamwork is important. "The concept can only succeed when everyone is on board," concluded Prof. Ender.

Göttingen case study: chest tube management as part of post-operative care

"Based on the results, the  Thopaz+ digital chest drainage and monitoring system* is now used as standard for post-operative drainage therapy in cardiac surgery patients at University Hospital Göttingen."
* Monitoring of fluid drainage, air leak and pressure

The aim of post-operative chest tube management after cardiac surgery is to drain wound exudate such as blood and serum from the pericardium or the pleura as completely as possible, to avoid "retained blood syndrome". Retained blood increases the risk of re-intervention due to inflammation8 and leads to higher hospital mortality and other post-operative complications9, says Prof. Baraki, Senior Consultant and Cardiac Surgeon at the Cardiothoracic Surgery Clinic at University Hospital Göttingen.

Furthermore, there is the concern that chest drains, despite their large diameter, could become entirely or partially occluded. One study10has shown that inadvertent occlusion occurs in 36% of chest tube drains, and that 86% of these occlusions occur inside the patient, meaning that they are below the skin and are therefore not visible. Mechanical manipulation strategies such as milking/stripping and aspirating in the most sterile environment possible are no longer recommended due to high negative pressure and the high risk of injury to intrathoracic structures. Therefore, they are obsolete, suggested Prof. Baraki.

The problem of clotting is dealt with relatively well thanks to a new chest drain with active clearing technology, which a recent study showed was able to reduce retained blood syndrome by 43% and thus reduce atrial fibrillation by 33%.11 As well as enabling efficient drainage without inadvertent occlusion in the system, cardiothoracic surgeons have other requirements of optimal drainage systems, namely:

  • Continuous uninterrupted suction, for example while transporting the patient from the operating theatre to the intensive care unit.
  • Objective data monitoring.
  • Alarm system.
  • Ability to introduce early mobilization.

Prof. Baraki then presented as-yet-unpublished results of a retrospective study from her own department in which 265 cardiac surgery patients were analyzed according to the drainage system (analogue v. digital) used.12 The results showed that the digital system was significantly better when it came to drain output at the early post-operative stage. This study showed that the digital system performed significantly better regarding nurse and medical staff satisfaction of patient mobilization, handling and documentation. The analysis showed that more clotting appeared on the connections to the digital system, but this had no impact on re-operations and complication rates.

Based on the results, the  Thopaz+ digital chest drainage and monitoring system is now used as standard for post-operative drainage therapy in cardiac surgery patients at University Hospital Göttingen, comments Prof. Baraki.

Conclusion

At the end of the symposium, all participants agreed that the aim of ERAS should ultimately be to treat all patients as if they were in a position to recover quickly. Initially pre-selecting low-risk patients helps to establish infrastructure and logistics. The program can be extended to cover high-risk patients as well. It remains to be seen whether, the ERAS concept could offer high-risk patients an even greater opportunity for improved outcomes.

Medela Medizintechnik would like to thank the chair and the experts for taking part and for their fascinating presentations and discussions.

Note: Prof. Baraki could not participate in the symposium in person and she attended the event via live stream as the first speaker.

Thopaz+ takes chest drainage therapy to a new level of care

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References

1. The International Surgical Outcomes Study group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth 2016;117(5):601-609.

2. Greco M, Capretti G, Beretta L, et al. Enhanced Recovery Program in Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials. World J Surg 2014;38(6):1531-41.

3. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations.

4. Williams JB, McConnell G, Allender JE, et al. One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program. J Thorac Cardiovasc Surg 2019;157(5):1881-8.

5. Wong WT, Lai VKW, Chee YE, et al. Fast-track cardiac care for adult cardiac surgical patients (Review). Cochrane Database Syst Rev 2016;12:9:CD003587.

6. Ender J, Borger MA, Scholz M, et al. Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept. Anesthesiology 2008;109(1):61-6.

7. Probst S, Cech C, Haentschel D, et al. A specialized post-anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized controlled trial. Crit Care 2014;18(4):468.

8. Boyle et al. Retained Blood Syndrome After Cardiac Surgery: A New Look at an Old Problem. Innovations (Phila) 2015;10(5):296-303.

9. Balzer F, von Heymann C, Boyle EM, et al. Impact of retained blood requiring reintervention on outcomes after cardiac surgery. J Thorac Cardiovasc Surg 2016:152:595-601.

10. Karimov JH, Gillinov AM, Schenck L, et al. Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study. Eur J Cardiothorac Surg 2013:44(6):1029-36.

11. Sirch J, Ledwon M, Püski T, et al. Active clearance of chest drainage catheters reduced retained blood. J Thorac Cardiovasc Surg 2016:151(3):832-8.

12. Saha S, Hofmann S, Jebran AF, et al. Safety and efficacy of digital chest drainage units compared to conventional chest drainage units in cardiac surgery. Interact Cardiovasc Thorac Surg 2020;31(1):42-47.