ERAS in cardiac surgery - from theory to practice

Recap of the lunch symposium at the DGTHG Annual Meeting on 2 March 2020

The concept of "Enhanced Recovery after Surgery" (ERAS®) is attracting more and more attention in many surgical specialities. The measures recommended in the recently published ERAS Cardiac Guidelines and how ERAS® can be implemented in cardiac surgery day-to-day were the subject of the well-attended symposium held as part of the 49th DGTHG Annual Meeting in Wiesbaden.

Introducing the ERAS® Cardiac Guidelines

"Surely a cohort of patients where it makes sense to think about whether complications could be avoided."

With a post-operative complication rate of ⅓ to ¼ globally, it is a topic that we need to engage with: this is how Professor Sander, Senior Consultant in Anaesthesia and Intensive Care Medicine at the University Hospital of Giessen, introduced the theme of the symposium.

Prof. Sander cited a multicentre trial, published in 2016, in which data from over 44,000 patients from nearly 500 hospitals in 27 countries were analysed. 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 "Surely a cohort of patients where it makes sense to think about whether complications could be avoided," commented Prof. Sander. He emphasised that in the post-operative setting, the risk of experiencing a complication is 1,000 times higher in the first 30 days.

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

Since May 2019, there have been guidelines for cardiac surgery, too.3 Based on data from around 200 publications, colleagues published 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 remains a lot to do. One question for future trials will certainly involve establishing which of the measures in the Guidelines need to be implemented and which are less important.

Establishing an ERAS® concept in cardiac surgery

Prof. Girdauskas, Cardiac Surgeon and Executive Senior Consultant at the Cardiac and Vascular Centre at University Medical Centre Hamburg-Eppendorf (UKE), reported on 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 anaesthetists, physiotherapists and cardiologists, spent a week shadowing the cardiac surgery department at Sancta Maggiore hospital. With an established model and a team with years of experience, their Brazilian colleagues succeeded in establishing a protocol whereby cardiac surgery patients could be discharged from hospital on the first post-operative day following 24 hours in a good condition.

Based on this, they derived measures for the Hamburg model which are consistent with the German DRG and OPS model, says Prof. Girdauskas. For the pilot phase, they used pre-selection criteria to primarily include healthier patients who had undergone minimally invasive valve surgery.

"Another important component is early mobilisation of the patients. This includes extubation while they are still in the operating theatre, breathing exercises and first mobilisation in the recovery room, with follow-up mobilisation sessions in the evening and over the next few days."

He believes that the package of interacting measures is vital to success, with pre, intra and post-operative pillars, as he demonstrated in his presentation in detail. There are two components that Prof. Girdauskas sees as unquestionably important: on the one hand, the interdisciplinary outpatient explanatory conversation (2-3 weeks before the operation) which is labour-intensive for the hospital but is very well-received by patients as they feel well supported. The patient learns how the ERAS programme 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.

Another important component is early mobilisation of the patient, says Prof. Girdauskas. This includes extubation while they are still in the operating theatre, breathing exercises and first mobilisation in the recovery room, with follow-up mobilisation sessions in the evening and over the next few days.

Initial data from the pilot phase show that implementing the concept can significantly reduce the duration of a patient's stay in the intensive care unit and of hospitalization overall. In this connection, Prof. Girdauskas referred once again 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 future as part of a randomised 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 case study: PACU*

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

"A 12-hour stint in the recovery room is better than 24 hours."

Among other things, this provides for patients who have undergone cardiac surgery ideally moving from the recovery room* to intermediate care on the same day, then to the normal ward, without spending time in the intensive care unit in most cases.

What started in November 2005 with a recovery room equipped with three beds, is now, with 8 beds, a fixture 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 concept are identified using simple target criteria. These patients were at the top of the operating schedule thanks to pre-selection.

"It is simply worth thinking about the structures", says Prof. Ender, illustrating this with the data from Leipzig.6When the patient comes into the intensive care unit, they are staying 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 randomised 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, and the opportunity to comply strictly with the set protocols.

An evaluation also showed that a 12-hour stint 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.

* Post-Anaesthesia Care Unit, PACU for short (recovery room)

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

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 volume, could become wholly or partially occluded. One study has shown that10 inadvertent occlusion occurs with 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, and they are therefore obsolete, suggested Prof. Baraki.

"Based on the results, the digital cardiothoracic system Thopaz+ is now used as standard for post-operative drainage therapy in cardiac surgery patients at University Hospital Göttingen."

The problem of clotting is dealt with relatively well thanks to a new chest drain, a closed system with active sterile drain cleaning, 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, an alarm system and the ability to introduce mobilisation early, states Prof. Baraki.

On this point, Prof. Baraki went on to present as-yet-unpublished results of a retrospective study from her own department in which 265 cardiac surgery patients were analysed 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. When it came to care and medical staff satisfaction regarding patient mobilisation, handling and documentation, a study showed that the digital system performed significantly better. The analysis showed that when it was attached, more clots were documented with the digital system, but with no impact on revision and complication rates.

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

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. Pre-selecting low-risk patients helps to establish infrastructure and logistics initially. It is feasible to extend the programme to cover high-risk patients as well. It remains to be seen whether, with high-risk patients, the ERAS concept offers an even greater opportunity to improve 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.

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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. JAMA Surg 2019;154(8);755-66.

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.