2021 - Perioperative care in cardiac surgery

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Matrix codes: 1A01,
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BJA Education, 21(10): 396e402 (2021)
doi: 10.1016/j.bjae.2021.05.008
Advance Access Publication Date: 13 July 2021
Perioperative care in cardiac surgery
S. Pokhrel1,*, A. Gregory2 and A. Mellor1
1James Cook University Hospital, Middlesbrough, UK and 2University of Calgary, Calgary, Canada
*Corresponding author. savin.pokhrel@nhs.net
Keywords: cardiac surgery; enhanced recovery; perioperative care
Key points
� Perioperative care refers to the care of the patient
from the point at which surgery is first considered
through to their recovery.
� Enhanced recovery is a new but growing concept
for cardiac surgical patients.
� Prehabilitation is a multimodal approach to
enhance an individual’s functional capacity to
withstand the stress of surgery.
� Patient bloodmanagement (PBM) involves using a
range of interventions to avoid unnecessary
blood transfusions and hence improve outcomes.
� Greater compliance to a pathway is associated
with better clinical outcomes.
Learning objectives
By reading this article you should be able to:
� Identify the key components of the enhanced
recovery after surgery (ERAS) pathway for pa-
tients undergoing cardiac operations.
� Discuss the multiple factors involved in recovery
after cardiac surgery.
� Review strategies to reduce the use of opioids in
the ERAS pathway.
Perioperative medicine is a growing area of interest within
anaesthesia, critical care and surgical specialties worldwide.
In recent years enhanced recovery after surgery (ERAS) prin-
ciples have become central to high-quality care in many sur-
gical specialties. These ERAS principles are based upon the
development of evidence-based protocols to engage patients
in their care, reduce the stress response to surgical trauma
and enable the patient to recover normal function more
rapidly after major surgery. These goals are achieved through
consistent application of evidence-based best practices and
Savin Pokhrel FRCA is a speciality trainee in anaesthesia at James
Cook University Hospital, Middlesbrough who has completed a
fellowship in cardiac enhanced recovery.
Adrian Mellor MD FRCA is a consultant cardiothoracic anaesthetist
at James Cook University Hospital. He is a visiting professor at Leeds
Beckett University, has given invited lectures on ERAS and has
instituted a cardiac ERAS programme.
Alexander Gregory MD FRCPC is a cardiac anaesthesiologist and
assistant professor in the Department of Anesthesiology, Perioper-
ative and Pain Medicine at the Cumming School of Medicine, Uni-
versity of Calgary and a member of the Libin Cardiovascular
Institute. He is an Executive Board member of the ERAS Cardiac
Society and has published articles and given invited lectures on
enhanced recovery for cardiac surgery.
Accepted: 17 May 2021
© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights rese
For Permissions, please email: permissions@elsevier.com
reducing unnecessary clinical variation. The potential for
improving patients’ and healthcare system’s outcomes has
increased in our modern era of increasingly complex patients,
and new developments in anaesthetic and surgical tech-
niques, despite growing constraints on healthcare budgets.
Overall, this fundamentally shifts the traditional paradigm of
care from an individual clinician model, to a holistic, collab-
orative, multidisciplinary approach that aims to optimise the
patient’s experience and outcomes.
Although rooted in the approach originally championed by
the early founders of ERAS for non-cardiac surgery, there are
several important differences in the development of pro-
grammes for patients undergoing cardiac surgical procedures.
These differences present both unique challenges and opportu-
nities in the development and implementation of ERAS pro-
grammes in cardiac surgery. In the 1980s, increased demands,
limited resources and economic pressures led many centres to
initiate ‘fast-track’ care pathways. These pathwayswere focused
on reducing the time to tracheal extubation as ameans to reduce
ICU stay, and they differ significantly from a holistic patient-
centred ERAS approach. The ERAS Cardiac Society has recently
published evidence-driven recommendations for pathways to
optimise patients’ care in cardiac surgery.1
rved.
396
mailto:savin.pokhrel@nhs.net
https://doi.org/10.1016/j.bjae.2021.05.008
mailto:permissions@elsevier.com
Table 1 Cardiac enhanced recovery pathway (reproduced from NHS Improvement for use in South Tees Hospital). PPI, proton pump
inhibitor
Referral from
primary care
Preoperative Admission Intraoperative Postoperative Follow-up
� Optimising
haemoglobin
concentrations
� Managing
pre-existing
comorbidities
(e.g. diabetes,
hypertension)
� Health and
risk assessment
� Good quality
patient information
� Informed
decision-making
� Patient
surgery school
� Optimised
health/medical
conditions
� Therapy advice
� Nutritional advice
� Discharge planning
� Admit on
night before or
day of surgery
� Optimise
fluid hydration
� Minimise
fasting period
(i.e. solids 6 h
liquids 2 h)
� Avoid routine
use of sedative
premedication
� Carbohydrate
preloading
� Gabapentin and PPI
� Surgical
site infection
reduction
� Temperature
management
� Tranexamic acid
� Opioid-sparing
analgesics
� Use of
local anaesthetic
to wound and
drain sites
� Antiemetic
prophylaxis
� Sedation hold
and extubation
� Active,
planned
mobilisationwithin 4
h of extubation
� Systematic delirium
screening
� Early oral hydration
� Early oral nutrition
� Early drains
and catheter
removal
� Glycaemic control
� Thromboprophylaxis
� Avoidance
of systemic opioid-
based analgesia
when possible
� Discharge
on planned day or
when criteria met
� Therapy support
(physiotherapy,
dietician,
community nurse)
� 24 h telephone
follow-up if
appropriate
Perioperative care in cardiac surgery
Cardiac surgery covers a range of surgical techniques and a
variety of physiological insults that may have an impact on
postoperative recovery. As in any other specialty, the patient’s
own pre-existing comorbidities have the greatest effect on
outcome. These factors include the condition requiring sur-
gery such as acute infective endocarditis and pre-existing
conditions such as anaemia, diabetes or chronic kidney dis-
ease (CKD). The urgency, complexity and duration of both
surgery and cardiopulmonary bypass (CPB) all have a major
influence on recovery. Complex surgery requiring long CPB
times, the use of profound hypothermia, reduced cerebral
perfusion and potentially greater blood loss all increase
adverse events and prolong recovery. Postoperative compli-
cations such as bleeding, which may lead to cardiac tampo-
nade, acute kidney injury (AKI) and the requirement for
resternotomy, affect recovery and prevent ERAS goals being
achieved. Despite all these complexities, the adherence to
multimodal, evidence-based pathways in the perioperative
period is fundamental for optimum benefit and the success of
the programme. However, a ‘one-size-fits-all’ approach will
inherently risk limiting the potential benefits for patients, fail
to achieve the desired gains in efficacy and reduce satisfaction
within the healthcare team. These conflicting principles must
be acknowledged to allow individual treatment and differ-
ences between units. Enhanced recovery after surgery pro-
grammes are a collection of interventions, which alone may
be of little benefit but when taken as a collective pathway
result in significant gains and improvement in the patient’s
experience and outcome.
Patients presenting for cardiac surgery are likely to benefit
from an ERAS programme as there are common features in
the nature of the surgery and patients’ characteristics. The
basic steps involve ensuring that the patient presents for
surgery in the best possible physical and psychological con-dition. Management during surgery is optimised to agreed
best practice, and every effort ismade to ensure early recovery
of function (such as mobility and nutrition). Table 1 illustrates
this approach.
Preoperative preparation
The patient should be at the centre of their ‘contract of care’.
This involves providing sufficient information to obtain
informed consent for surgery, but also a detailed discussion of
anticipated events, the importance of preoperative in-
terventions (see below) and expectations about early mobi-
lisation and return to normal function. This timely and honest
discussion is an essential part of enhanced recovery and relies
upon consistent transfer of good quality information.
Before referral from primary care
Many patient-related risk factors can be modified by changes
in behaviour or medication before referral. These should be
started early in the progress by the referring physician (usu-
ally a cardiologist) with the patient’s primary care doctor
playing an active role. Initial screening of fitness for surgery
should identify risk factors such as poorly controlled diabetes
or hypertension, and factors associated with an increase in
complications such as anaemia or impaired renal function.
Behavioural changes can address alcohol intake, cigarette
smoking and poor cardiorespiratory fitness.2 By establishing
these plans early, best use can be made of the time between
referral and an outpatient appointment. Primary care physi-
cians can also provide information on extra support that may
be needed such as social care on discharge from hospital.
Risk assessment and stratification
All patients undergoing cardiac surgery have a thorough risk
assessment to score for intraoperative risk. Models such as
the European System for Cardiac Operative Risk Evaluation
BJA Education - Volume 21, Number 10, 2021 397
Perioperative care in cardiac surgery
(EuroSCORE) and Society of Thoracic Surgeons (STS) adult
cardiac surgery risk score can be used to identify high-risk
patients. These risk scoring systems focus on the overall risk
for the procedure and do not, necessarily, involve a holistic
consideration of the patient’s other comorbidities and modi-
fiable factors. This information provides a greater under-
standing for the patient, improves decision-making, allows
preoperative optimisation and enables the surgical technique
or procedure to be altered if needed.
Adequate preoperative glycaemic control is defined as a
haemoglobin A1c (HbA1c) concentration value �6.5%; opti-
mising glycaemic control reduces morbidity and post-
operative complications such as myocardial injury and
surgical site infections. Similarly, hypoalbuminaemia can be a
useful marker to identify patients at increased risk of pro-
longed mechanical ventilation, AKI, infectious complications,
longer hospital stay and increased mortality. The cardiac
ERAS guidelines recommend measuring HbA1c and albumin
to assist with risk stratification, with a moderate quality level
of evidence.3
Patients with low Hb concentrations have a far higher in-
hospital mortality than those with normal concentrations.
For example, an Hb concentration �10 g dl�1 is associated
with a five-fold increase in mortality, and lesser degrees of
anaemia are also associated with increased risks of morbidity
and mortality.4 Anaemia should be investigated before car-
diac surgery and treated where possible.5 Iron deficiency is
one of the most common causes of anaemia before surgery,
and underlying causes should be excluded. Patients will
sometimes present for cardiac surgery with an identified
cause of anaemia, such as malignancy or CKD, which requires
good patient blood management with iron, transfusion, or
both. Oral iron therapy is tolerated poorly and may be less
effective in treating anaemia, particularly in the period shortly
before surgery. Intravenous iron, such as ferric carbox-
ymaltose preparations, may be better for a quicker and more
sustained response. Iron therapy should also be considered
(with or without erythropoiesis-stimulating agents) in
anaemia of chronic disease where, despite normal or high
serum ferritin concentration, there may be concurrent abso-
lute or relative iron deficiency.6 Studies are currently under-
way to determine the impact of preoperative iron therapy on
transfusions and outcomes after cardiac surgery.
Prehabilitation
Prehabilitation is the process of augmenting a patient’s
functional status to withstand the stress of subsequent sur-
gery. This includes education, correcting nutritional de-
ficiencies, optimising physical fitness and providing
psychological and social support. The net result of these in-
terventions is to reduce the patient’s anxiety and increase
their understanding of the surgical process.
Cardiac surgery school
The concept of multidisciplinary surgery school in cardiac
surgery is a novel approach. Surgery school provides an
environment for the patient and their relatives to learn and
about their perioperative course and how they can influence
it. This helps to reduce psychological stress and improve their
recovery. The education can take place face to face or via an
online programme. At James Cook University Hospital the
patient views educational videos on digital devices whilst
waiting in the clinic. These sessions emphasise the
398 BJA Education - Volume 21, Number 10, 2021
importance of being active, living well, eating well and phys-
ical training to improve respiratory and muscle function
before the surgery.
Preoperative exercise
Exercise programmes that improve physical fitness are
deemed safe in patients with cardiorespiratory conditions,
although current evidence in cardiac surgery is limited.2 This
can be high-intensity interval training alone or in combina-
tion with muscular strength training. A preoperative exercise
programme may decrease perioperative sympathetic dysre-
gulation and insulin resistance, and increase the ratio of lean
body mass to body fat.7 Additional benefits include improving
the patient’s physical and psychological readiness for surgery,
reducing postoperative complications, shortening length of
stay and improving the patient’s experience during recovery
before returning home.8 This needs to be individualised ac-
cording to a patient health status.
Lifestyle modifications
Smoking, excessive alcohol use and obesity are all associated
with perioperative complications and poorer outcomes and
should be screened for before surgery. Serious cardiorespira-
tory complications and wound infections can be significantly
reduced with abstinence from smoking starting 3e8 weeks
before surgery. The main points of preoperative intervention
are individual counselling to explain the results and benefits
of abstinence, and how to manage immediate withdrawal
symptoms.9
Minimisation of fasting and giving a preoperative
carbohydrate load
Giving clear fluids up to 2 h before induction of anaesthesia
has been previously shown to be safe.10 A carbohydrate drink
(typically containing 24 g complex carbohydrate) 2 h before
surgery has been a mainstay of most ERAS programmes. In
non-cardiac patients this practice has led to reduced insulin
resistance and tissue glycosylation, more stable postoperative
glucose concentrations and earlier return of normal gastro-
intestinal function.11 A Cochrane review found that giving
carbohydrate drinks before cardiac surgery is safe and im-
proves cardiac function immediately after CPB.12 For these
reasons ERAS programmes usually include preoperative car-
bohydrate drinks the night before and 2 h before surgery.
Intraoperative interventions
Reducing surgical site infections
The incidence of surgical site infection is 1.1e7.9%. This pro-
longs the duration of hospital stay, increases healthcare-
related costs and is associated with high morbidity and mor-
tality after cardiac surgery.13 A care bundle to reduce surgical
site infectionsshould include topical intranasal therapies to
eradicate staphylococcal colonisation, weight-based doses of
cephalosporin antibiotics between 30 and 60 min before skin
incision (repeated after 4 h if surgery is ongoing), skin steri-
lisation with cleaning solution and depilation protocols with
dressing changes every 48 h.14 Smoking cessation, adequate
glycaemic control and maintaining normothermia after sur-
gery also play a vital role.
Perioperative care in cardiac surgery
Avoiding hyperthermia
Cardiopulmonary bypass may be carried out at normothermic
or hypothermic body temperatures. The efficiency of heat
exchangers means that patient can be subjected to inadver-
tent hyperthermia especially during rewarming from hypo-
thermic CPB. Excessive hyperthermia during rewarming is
defined as a core temperature >37.9�C and is associated with
increased postoperative neurological injury, infection and
renal dysfunction. Guidelines for rewarming to mitigate these
risks have been published (Table 2).15
Blood management and tranexamic acid
Bleeding after cardiac surgery is a common complication, with
a very significant impact. Rates of resternotomy vary between
0.69% and 7.6% in different units, but the impact is significant;
the mortality rate is 15% after resternotomy and so it is of
paramount importance to reduce the risk of postoperative
bleeding.16 Intraoperative tranexamic acid reduces the need
for blood transfusion, major haemorrhage or tamponade
requiring reoperation.17 Amaximum total dose of 100mg kg�1
is recommended as higher dosages are associated with sei-
zures. Reducing perioperative red blood cell transfusion in-
volves correction and optimisation of haemoglobin before
surgery, intraoperative blood scavenging and avoiding post-
operative hypothermia. The use of data-driven transfusion
algorithms supported by comprehensive point-of-care coag-
ulation testing can guide transfusion choices and reduce the
use of blood products.18 The effect of CPB on platelet function
may make the use of a higher platelet count (>750,000 L�1)
necessary after bypass.19
A reduction in bleeding in the immediate postoperative
phase is crucial in meeting the ERAS goals of early tracheal
extubation, mobilisation and restarting oral diet.
Postoperative care
Multimodal, opioid-sparing analgesia
Adequate analgesia is key and needs to be considered before,
during and after surgery. Pain has undesirable physiological
Table 2 Recommendations for temperature management during CP
Issue 2, pp. 748e57, August 1, 2015). CPB, cardiopulmonary bypass
Optimal site for temperature
measurement
e The oxygenator arterial out
cerebral temperature measu
e Tomonitor cerebral perfusa
the oxygenator arterial outle
e Pulmonary artery catheter o
and immediate temperature
Avoidance of hyperthermia e Surgical teams should lim
hyperthermia.
Peak cooling temperature gradient
and cooling rate
e Temperature gradients from
cooling should not exceed 1
Peak warming temperature gradient
and rewarming rate
e Temperature gradients from
rewarming should not exce
patient.
Rewarming when arterial blood
outlet temperature is �30�C
e To achieve the desired tem
temperature gradient betwe
e To achieve the desired tem
rewarming rate of �0.5�C m
Rewarming when arterial blood
outlet temperature isadrenergic stimulation, limits mobilisation and
slows the progression of oral intake and diet. Published rates
of PONV in cardiac surgery are as high as 67%.23
Tracheal extubation
Prolonged postoperative ventilation is associated with
increasedmorbidity, mortality and prolonged stays in ICU and
hospital.24 Timely tracheal extubation has been an important
element of cardiac surgery quality improvement initiatives
since the earliest ‘fast-track’ protocols. Although prolonged
mechanical ventilation (defined as >24 h) is the current STS
quality metric, early extubation (defined as 8.8e9.9 mmol L�1) should be managed with a titrated
infusion of insulin; however, care must be taken to also
avoid hypoglycaemic events.
Managing temperature
Postoperative hypothermia is the failure to return to, or to
maintain, normothermia (>36�C) 2e5 h after admission to ICU.
Postoperative hypothermia is associated with increased
bleeding, infection, prolonged hospital stays and death. In
addition to ensuring adequate rewarming before separating
from CPB, use of forced air warming blankets, fluid warmers,
and raised roomambient temperature should all be considered.
Screening for delirium
Delirium is defined as a disturbance of consciousness and a
change in cognition that develops over a short period of time.
Approximately 50% of patients after cardiac surgery develop
delirium, which can be hyperactive, hypoactive or mixed
psychomotor behaviours. Delirium is associated with
decreased survival, in both the short and long term. In addi-
tion, it also leads to more hospital readmissions and dimin-
ished recovery of cognition and normal function. A systematic
delirium screening tool such as the Confusion Assessment
Method for Intensive Care Unit (CAM-ICU) or the Intensive
Care Delirium Screening Checklist (ICDSC) should be used at
least once during each nursing shift to identify delirium in a
timely fashion. A management plan should include assess-
ment of risk factors (patient, critical illness and iatrogenic),
screening and treatment. Techniques such as sedation holds,
orientation, correction of the sleepewake cycle and using vi-
sual and hearing aids should be used before starting drug
treatments. The goal of an ERAS programme should be to
minimise delirium and enable progression with postoperative
nutrition, mobilisation and recovery.
Removing drains and catheters early
ERAS programmes in other surgical specialities have moved
towards using no surgical drains or advocated the early
removal of drains and catheters. Immediately after cardiac
surgery most patients have some intrathoracic bleeding,
which needs to be evacuated via chest drains, and arterial
and central venous catheters are considered a minimum
standard of care. Chest tubes are prone to obstruction by
clots leading to retained mediastinal blood, compression of
the heart or lungs and potentially requiring a return to the
operating theatre. Even small volumes of retained medias-
tinal blood can promote a pro-inflammatory state, which
may result in pleural/pericardial effusions or postoperative
atrial fibrillation. Finally, retained mediastinal blood has
been previously linked to greater transfusion requirements,
rates of AKI, duration of mechanical ventilation, length of
stay and mortality. The common practice of milking or
stripping tubes is unlikely to be effective, and is potentially
harmful. Active chest tube clearance methods prevent oc-
clusion without breaking the sterile field, thereby
Perioperative care in cardiac surgery
maintaining inner lumen patency and reducing the volume
of retained blood.
Chest tubes and invasive lines should be removed as soon
as they are not required, according to clear protocols. Chest
drains can be safely removed once drainage is determined to
be serous on visual inspection.
Goal-directed therapy
Goal-directed therapy (GDT) is an algorithmic approach to
optimise a patient’s cardiovascular physiology, using the
comprehensive application of dynamic responsive monitors.
Although the exact monitors, decision pathways and in-
terventions may differ, meta-analysis of the data on the
standardised application of GDT protocols for cardiac surgery
has shown a reduction in hospital length of stay and com-
plications, but not ICU length of stay or mortality.30 Subgroup
analysis has shown that initiation in the operating room (with
continuation to the ICU) confers no additional benefit to a
protocol applied solely on arrival in the ICU.31 This suggests
that a GDT strategy might only achieve maximum benefit if it
includes a postoperative ICU phase, which is in contrast to the
majority of GDT literature in non-cardiac surgery. The next
progressin GDT for cardiac surgery may be within CPB tech-
niques, where early data are promising. Ongoing research
should help determine the most useful and cost-effective
monitoring strategy and GDT intervention bundles, but the
current evidence suggests the benefits of GDT warrant their
inclusion in cardiac surgery ERAS pathways.
AKI
Acute kidney injury contributes to morbidity and mortality
after cardiac surgery. Urinary biomarkers, such as tissue
inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like
growth factor binding protein 7 (IGFBP7), can identify pa-
tients at risk for developing renal injury before increases in
serum creatinine or reduced urine output.32 Activating a
renal-protection and haemodynamic optimisation bundle
based on the detection of urinary biomarkers has been
shown to reduce the incidence of AKI after cardiac
surgery.33
Conclusions
The development of ERAS programmes for cardiac surgery
draws on advances made in other surgical specialities to
reduce surgical trauma, improve patients’ experience and
lead to a more rapid recovery. This is a team-based approach
that puts patient at the centre of care and focuses on the
entire perioperative period. Transition from existing care to a
bundle of enhanced recovery interventions is not straight-
forward and relies upon good communication with patients
from the point of referral. The interventions are simple but
require the support from all disciplines involved to maximise
the benefits.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/homeby subscribers to
BJA Education.
Declaration of interests
The authors declare that they have no conflicts of interest.
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	Perioperative care in cardiac surgery
	Preoperative preparation
	Before referral from primary care
	Risk assessment and stratification
	Prehabilitation
	Cardiac surgery school
	Preoperative exercise
	Lifestyle modifications
	Minimisation of fasting and giving a preoperative carbohydrate load
	Intraoperative interventions
	Reducing surgical site infections
	Avoiding hyperthermia
	Blood management and tranexamic acid
	Postoperative care
	Multimodal, opioid-sparing analgesia
	Postoperative nausea and vomiting prophylaxis
	Tracheal extubation
	Active, planned mobilisation
	Perioperative glycaemic control
	Managing temperature
	Screening for delirium
	Removing drains and catheters early
	Goal-directed therapy
	AKI
	Conclusions
	MCQs
	Declaration of interests
	References