Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process (original) (raw)
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Guidelines for Perioperative Care in Cardiac Surgery
JAMA Surgery
nhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. 1 These programs aim to reduce complications and promote an earlier return to normal activities. 2,3 The ERAS protocols have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management in populations having noncardiac surgery. 4-6 Evidence-based ERAS protocols have been published across multiple surgical specialties. 1 In early studies, the ERAS approach showed promise in cardiac surgery (CS); however, evidence-based protocols have yet to emerge. 7 To address the need for evidence-based ERAS protocols, we formed a registered nonprofit organization (ERAS Cardiac Society) to use an evidence-driven process to develop recommendations for pathways to optimize patient care in CS contexts through collaborative discovery, analysis, expert consensus, and best practices. The ERAS Cardiac Society has a formal collaborative agreement with the ERAS Society. This article reports the first expert-consensus review of evidence-based CS ERAS practices. Methods We followed the 2011 Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, using a standardized algorithm that included experts, key questions, subject champions, systematic literature reviews, selection and appraisal of evidence quality, and development of clear consensus recommendations. 8 We minimized repetition of existing guidelines and consensus statements and focused on specific information in the framework of ERAS protocols.
Improving Cardiac Outcomes After Noncardiac Surgery
Anesthesia & Analgesia, 2003
T here has long been interest in reducing cardiovascular complications after surgical operations (specifically, myocardial ischemia, myocardial infarction [MI], or cardiac death). In this issue of Anesthesia & Analgesia, two articles are presented on this general topic. The first article systematically reviews various drug options for prevention of adverse cardiac outcomes during and after noncardiac surgery (1). The second article describes a meta-analysis of outcomes with the use of calcium channel blockers (CCBs), concluding, in partial conflict with the results of the first, that CCBs may be underused primarily because of a "North American bias" against this drug class (2).
Acta Anaesthesiologica Scandinavica, 2011
Background: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggest measures for prioritized future investigation we performed the first international consensus conference on this topic. Methods: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. Results: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation, referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. Conclusion: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood may result in an increased mortality.
SubmIttEd to opEN-hEArt SurgEry: A
2008
BACKGROUND: The objective of this study was to investigate the relationship between different target levels of glucose and the clinical outcomes of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: We designed a prospective study in a university hospital where 109 consecutive patients were enrolled during a six-month period. All patients were scheduled for open-heart surgery requiring cardiopulmonary bypass. Patients were randomly allocated into two groups. One group consisted of 55 patients and had a target glucose level of 80-130 mg/dl, while the other contained 54 patients and had a target glucose level of 160-200 mg/dl. These parameters were controlled during surgery and for 36 hours after surgery in the intensive care unit. Primary outcomes were clinical outcomes, including time of mechanical ventilation, length of stay in the intensive care unit, infection, hypoglycemia, renal or neurological dysfunction, blood transfusion and length of stay in the hospital. The secondary outcome was a combined end-point (mortality at 30 days, infection or length of stay in the intensive care unit of more than 3 days). A p-value of <0.05 was considered significant. RESULTS: The anthropometric and clinical characteristics of the patients from each group were similar, except for weight and body mass index. The mean glucose level during the protocol period was 126.69 mg/dl in the treated group and 168.21 mg/dl in the control group (p<0.0016). There were no differences between groups regarding clinical outcomes, including the duration of mechanical ventilation, length of stay in the intensive care unit, blood transfusion, postoperative infection, hypoglycemic event, neurological dysfunction or 30-day mortality (p>0.05). CONCLUSIONS: In 109 patients undergoing cardiac surgery with cardiopulmonary bypass, both protocols of glycemic control in an intraoperative setting and in the intensive care unit were found to be safe, easily achieved and not to differentially affect clinical outcomes.
Objective Therapy for Cardiac Surgery: Systematic Study and Meta- Analysis
2020
Aim: Perioperative mortality after heart medical procedure has diminished lately albeit postoperative grimness is as yet huge. In spite of the fact that there is proof that perioperative objective coordinated hemodynamic treatment may decrease careful mortality also, bleakness in non-cardiovascular careful patients, the information is less clear after heart medical procedure. The target of this survey is to play out a meta-examination on the impacts of perioperative GDT on mortality, bleakness, and length of emergency clinic remain in heart careful patients. Methods: We performed a precise audit using Medline, EMBASE and the Cochrane Managed Clinical Trials Registry. Specialists have been digging for alternative outlets. Our current research was conducted at PIMS Hospital, Islamabad from May 2018 to April 2019. The rules for integration were randomized controlled preliminary trials, detailed mortality as a result, pre-emptive hemodynamic mediation, and cardiac cautious population. Included investigations is examined in full and, where conceivable, subject to quantifiable analysis, subgroup investigation and affectability examination. The information mixture was derived by using the odds ratio (OR) and the mean comparison for consistent information with the 95 percent certainty stretch (CI) using an arbitrary effect model. Results. From 4989 probable examinations, 5 had complied with all the integration steps (704 patients). The quantitative investigation found that the use of GDT reduced the postoperative intricacy rate (or again 0.34, 96 per cent CI 0.16-0.74; P1⁄40.007) and the duration of the stay of the clinic (MD 24.45, 97 per cent CI 25.04 to 22.86; P1⁄40.003). There was no substantial drop in mortality. Conclusion: The utilization of pre-emptive GDT in cardiovascular medical procedure diminishes grimness and emergency clinic length of remain.