Select patients born with heart defects who are undergoing congenital heart surgery recover with few complications and reduced opioid use when a comprehensive, evidence-based ERAS (Enhanced Recovery After Surgery) program is used. This emerges from research presented by thoracic surgeons at the Society's 57th annual meeting.
"We introduced a new paradigm for patient care to improve recovery, the patient experience and the value of the care we offer," said Dr. Nathalie Roy of Boston Children's Hospital in Massachusetts. "The first results show that such programs can bring about a change in cardiovascular care."
Dr. From October 2018 to February 2020, Roy and colleagues collected data from eligible patients who had undergone elective surgery for simple or moderately complex congenital heart defects at Boston Children's Hospital. During the study period, 559 patients underwent congenital heart surgery as part of a protocol. powered, multidisciplinary ERAS cardiac surgery program. The ERAS patients were identified prior to surgery while the decision to stay in the program was based on surgical results.
The patient results were checked according to the implementation period (P1): October 2018 to February 2019 and after an early experience period (P2): March 2019 to February 2020.
Overall, the researchers found that several factors improved significantly from P1 to P2 as the program became more complex and advanced over time, familiarity, and experience. The study showed an increase in extubation in the operating room, ie the removal of the breathing tube, with 27% of P2 patients being extubated in the operating room versus 16% of P1 patients. Patients in the P2 group also had a shorter ventilation time in the ICU: 6.1 hours for P2 versus 7.6 hours for P1.
In general, ICU and postoperative length of stay did not differ significantly between the two groups, except for procedures with lower risk. Congenital heart operations are divided into so-called STAT categories according to the complexity of the procedure. STAT category 1 contains the least complex operations and STAT category 5 contains the most complex operations. Fewer hours were spent in the intensive care unit for operations in STAT category 2: 25.7 hours for P2 patients versus 34.6 hours for P1.
Importantly, the data also showed excellent pain control with an opioid-sparing approach that in certain cases included additional medication and regional anesthetic approaches. Reducing opioid use has potential benefits in speeding recovery, while regional anesthesia research is underway at Boston Children's Hospital.
In addition, the study showed a consistently low rate of complications, reoperations and readmissions.
"Our program defined a comprehensive approach to care throughout the surgical journey," said Dr. Roy. "We were able to remove the air tubing earlier after surgery and manage the pain well with opioid-sparing strategies – these are key components of an improved recovery program after congenital heart surgery."
ERAS is a set of pre-designed activities, steps, and guides designed to help speed recovery and the best possible outcomes for patients undergoing major surgery. It was first popularized in Denmark in the 1990s and has become more prevalent since then. In recent years, ERAS protocols have been integrated into many surgical specialties, with congenital cardiac surgery now joining movement.
"ERAS has been shown to improve key metrics in perioperative surgical care and lead to beneficial patient outcomes," said Dr. Lauren C. Kane of New Orleans Children's Hospital, Louisiana, who was not directly involved in this research. "Through the work of Dr. Roy and colleagues, the use of ERAS programs in pediatric and adult congenital cardiac patients has moved closer to nationwide universal acceptance."
Despite the encouraging early results of this step-by-step approach, researchers recognized that much remains to be done. For example, despite using this comprehensive ERAS program, compliance and use were not optimal for all program steps. The challenges of introducing new protocols in a large institution are diverse. However, the regular feedback reviews with multidisciplinary team members are critical to program improvement, regulatory compliance, and vendor acceptance. It is also important to empower patients and their families through education before and during the entire program.
However, this ERAS program showed promising results in the early stages for lower variability in care, optimization of resource use, and accelerated recovery from surgery – all of which ultimately have the potential to improve overall family and patient experiences and to increase patient outcomes improve.
The ERAS Heart Program, launched in 2018 at Boston Children's Hospital, encompasses all phases of patient surgical care, from preoperative to postoperative home care. The program offers key strategies such as less fasting, multiple approaches to pain management, minor surgical incisions if necessary, blood preservation, early extubation, removal of leads, tubes, and catheters as soon as possible, waking up early after surgery, and a quick return to normal diet. The program also includes advanced surgical follow-up with early virtual visits and patient-reported results surveys to monitor complications.
The ERAS program for children in Boston continues to evolve based on feedback gathered in monthly quality improvement meetings. In order to enable permanent programmatic improvements, Dr. Roy and colleagues also created an interactive dashboard that connects to the Boston Children's Hospital's ERAS database. The dashboard, updated in real time, enables visualization of performance metrics, which can be filtered by parameters such as age group and surgical complexity for in-depth analysis.
"An ERAS program requires institutional commitment and the involvement of stakeholders at all levels of the heart center," said Dr. Roy. "In congenital cardiac surgery, our program is in its early stages. The data are promising, but more research is needed, particularly on certain components of care for which there is sometimes little evidence in this population."
Future studies and ongoing researcher efforts will focus on pain and opioid sparing strategies, factors related to postoperative nausea and vomiting, the effects of transfusions on outcomes, and prehabilitation.
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The Society of Thoracic Surgeons
The ERAS program accelerates the recovery of patients with congenital heart surgery (2021, January 31).
accessed on January 31, 2021
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