It seems they are making an ERAS protocol for everything. Where I work is extremely excited to apply ERAS to anything they can. Anybody have experience with Cardiac ERAS? To be honest from anesthesia side doesn’t seem much different than what we already do.
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Cardiac ERAS
Started by midazzoler
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At asa a few years ago I saw that people were doing a lot of regional for pump cases. Pecs blocks, serratus, esp, pvb which really cut down on the opioid use intraop and people are extubating very early.
I know ACCRAC podcast has talked about them doing this at Hopkins. They've talked about starting patients on amiodarone pre-op to reduce perioperative a-fib. Not sure what else they do.
What's very early? On the table?
Don't remember exactly and I don't want to speak for others. We were extubating our robot valves on the table but that's a different beast.
I rotated cardiac in Kaiser in Portland while in residency, they extubate in the room after standard straight forward cabg and valves both on and off pump. No regional performed, minimize opioids. I'm not sure if they had a defined ERAS protocol, per se, it was just how they practice.
Some things we do at my institution:
Preop gabapentin, Tylenol. Intra-op: multimodal analgesia, minimize opioid use, glycemic control, protective tidal volume ventilation. Precedex gtt, low dose ketamine gtt, IV tylenol if > 6-8 hours after preoperative dose, postoperative blocks (usually SAP vs. PECS), early extubation if clinically appropriate.
Many CABGs get < 250 mcg fentanyl for the entire case and are extubated before leaving the room.
There’s a whole bank of literature on cardiac ERAS (including guideline recommendations) - I think a pretty comprehensive one was published in JAMA or one of the JAMA off-shoots with the past few years.
We’re “doing ERAS” with our cases, which amounted to adding preop nerve blocks (not sure if it helps, has become optional if there’s the chance it would slow the room down), Tylenol PO upfront, reviewing the literature on gabapentinoids (and subsequently not giving them to anyone), and reminding ourselves that patients don’t need 20mL Fent and 10mg Midaz.
The lion’s share of the work has been to get surgeons to not post the cases until patients stop smoking/get their A1c down/have their anemia addressed (let’s call that a “work in progress”), and to have the ICU endeavor to wake patients up ASAP (actually making progress here).
To be continued...
We’re “doing ERAS” with our cases, which amounted to adding preop nerve blocks (not sure if it helps, has become optional if there’s the chance it would slow the room down), Tylenol PO upfront, reviewing the literature on gabapentinoids (and subsequently not giving them to anyone), and reminding ourselves that patients don’t need 20mL Fent and 10mg Midaz.
The lion’s share of the work has been to get surgeons to not post the cases until patients stop smoking/get their A1c down/have their anemia addressed (let’s call that a “work in progress”), and to have the ICU endeavor to wake patients up ASAP (actually making progress here).
To be continued...
What are you really gaining with extubation in the OR vs after a few hours of observation in the ICU? You could do the case with only an epidural too. Also, while standing on one foot. But why?
It's all fun and games until you find yourself going back to re-explore a chest because the tube output is concerning and the unit nurses are escalating the drips ... a rare event some places, not so rare others.
I guess some people just like to make their lives harder than they need to be.
It's all fun and games until you find yourself going back to re-explore a chest because the tube output is concerning and the unit nurses are escalating the drips ... a rare event some places, not so rare others.
I guess some people just like to make their lives harder than they need to be.
A somewhat comprehensive sum of ERACS attached below.
Regional and precedex seem to play a dominant role.
Also needs a cultural change for ICU nurses and PAs to avoid overzealous resuscitation post-op because pt is “hypotensive” or because this is what we are used to doing years now.
I would love to read your intra-op tips to achieve a smooth extubation in the OR; that’s my goal but depends on many factors and will admit is not always easy;
is anything u use as a threshold to go or not for OR Extubation?
what I hate to see afterwards though is that persistent respiratory acidosis and hours and hours of 100% nonrebreather. 🙁(
Regional and precedex seem to play a dominant role.
Also needs a cultural change for ICU nurses and PAs to avoid overzealous resuscitation post-op because pt is “hypotensive” or because this is what we are used to doing years now.
I would love to read your intra-op tips to achieve a smooth extubation in the OR; that’s my goal but depends on many factors and will admit is not always easy;
is anything u use as a threshold to go or not for OR Extubation?
what I hate to see afterwards though is that persistent respiratory acidosis and hours and hours of 100% nonrebreather. 🙁(
