ERAS protocol, fast track , ultra

fast tracks
R2MU Edgar M Dominguez Cruz
 Introduction
 fast-track concept began with cardiac
surgery through various works by surgeons
such as Engelman , Krohn , or Westaby in
the 1980s and 1990s.
 Its purpose was to shorten times in the ICU
Introduction
 Kehlet in 1997, based on the
concepts of fast-track ,
introduces multidisciplinary
concepts and more
comprehensive care for patients
in the area of coloproctological
surgery .
 Definition
 The ERAS protocols ( Enhanced
Recovery After Surgery ) are a set
of multimodal perioperative
strategies that aim to reduce
hospitalization and recovery times,
perioperative complications and
costs associated with different
surgical procedures.

Chilean Journal of Anesthesia Vol. 48 No. 1 pp. 20-27|https://10.25237/revchilanestv48n01.05. 2018

 Definition
 fast protocols track and ultra
fast-track are techniques that
allow optimization of the
patient care process and rapid
recovery after surgery

A. Guerrero Gómez, N. González Jaramillo, JA Castro Pérez

ultra fast track extubation vs. conventional extubation after cardiac surgery in a cardiovascular reference center in Colombia. A longitudinal study Spanish Journal of Anesthesiology and
Resuscitation (English Edition ), Volume 66, Issue 1, January 2019, Pages 10-17
 ERAS – preoperative

Education, preoperative information to the patient and preparation before

the intervention

Avoid premedication

Prevention of prolonged preoperative fasting using oral carbohydrate

loading

Chilean Journal of Anesthesia Vol. 48 No. 1 pp. 20-27|https://10.25237/revchilanestv48n01.05. 2018

 ERAS intraoperative
antibiotics

Attenuate qx stress response (analgesia)

Maintain stable hemodynamics

Rational fluid management

Prevention of postqx nausea and vomiting

Maintain normothermia

Chilean Journal of Anesthesia Vol. 48 Núm. 1 pp. 20-27 | https: //10.25237/revchilanestv48n01.05. 2018
 You were postoperative

Early and aggressive mobilization

Start of early enteral nutrition

Protocol Compliance

Chilean Journal of Anesthesia Vol. 48 Num. 1 pp. 20-27 | https: //10.25237/revchilanestv48n01.05. 2018
 Fast track in cardiac surgery

Fast‐track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev. 2016 Sep ; 2016(9): CD003587. Published online 2016
Sep
 Fast track in cardiac surgery
 Series of complex procedures involving various components of anesthesia in
cardiac surgery and the postoperative period
 early extubation
 Reduce time in ICU

Fast‐track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev. 2016 Sep ; 2016(9): CD003587. Published online 2016
Sep
 Fast track in cardiac surgery
 Comparative study
 Objective: to determine the safety and
effectiveness of fast track vs conventional
care in adults with cardiac surgery
 Selection criteria: general anesthesia based
on low doses of opioids, early extubation

Fast‐track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev. 2016 Sep ; 2016(9): CD003587. Published online 2016
Sep
 Fast track in cardiac surgery
 Results:  Extubation was achieved up to 12 hours
 No difference in risk of death in the first earlier in the fast group tracks
year  The time in ICU was less
 No difference in risk of complications  The overall hospitalization time was similar
 reintubation  Fast track is safe
 YO SOY
 CVD
 No difference in risk of AKI, sepsis, and
wound infection.

Fast‐track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev. 2016 Sep ; 2016(9): CD003587. Published online 2016
Sep
 Fast track – Risk factors
 Certain factors prevent an adequate  low LVEF
evolution  Previous cardiac surgery
 Bypass surgery  By cardiopulmonary pass
 Advanced age
 female gender  Longer time in ICU
 Trans or post operative use of aortic balloon  Longer extubation time
 Use of inotropes
 bleeding
 Arrhythmia

Daniel Bainbridge, Davy Cheng, Current evidence on fast track cardiac recovery management, European Heart Journal Supplements , Volume 19, Issue suppl_A , January
2017, Pages A3–A7,
 Fast track conclusions
 The evidence indicates that the management of cardiac surgery with the fast protocol track with
early extubation is safe
 Cost-benefit
 Applies to valve and coronary surgeries
 With the advancement of surgical techniques and shorter CPB times, patients will be more
applicable to fast tracks

Daniel Bainbridge, Davy Cheng, Current evidence on fast track cardiac recovery management, European Heart Journal Supplements , Volume 19, Issue suppl_A , January
2017, Pages A3–A7,
Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 PREOPERATIVE HBA1C MEASUREMENT
 Adequate control of HbA1C (<6.5%) is associated with a lower risk of infection, ischemic
events, etc.
 Intentional search for diabetes preoperatively (up to 10% go undiagnosed)
 Up to 25% of CC px have HbA1C greater than 7%
 Greater glycemic control is associated with longer survival
 Class IIa recommendation , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 ALBUMIN MEASUREMENT
 Low levels of albumin in px of CC are associated with higher morbidity and mortality after qx
 Hypoalbuminemia is a pre qx prognostic value
 Associated with longer ventilator time, AKI, ICU stay, and mortality
 Class IIa recommendation , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 CORRECTION OF NUTRITIONAL STATUS
 In malnourished patients, oral supplementation 7 to 10 days prior to the qx event is associated
with a reduction in the risk of infections.
 In px of CC, albumin < 3g/dl with supplementation for 7 to 10 days have improved their results
 In cases of emergency it is not feasible
 Class IIa recommendation , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 CONSUMPTION OF CLEAR LIQUIDS PRIOR TO GENERAL ANESTHESIA
 Usual fasting of 6 to 8 hours in elective CC
 Several studies show safety in the consumption of clear liquids up to 2 hours prior to surgery
 Light meal up to 6 hours prior to CC
 Class IIIb , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 PRE OPERATIVE CARBOHYDRATE LOADING
 A 12 oz or 24 g carbohydrate drink 2 hours prior to surgery
 Reduces insulin resistance
 Improves PO glucose control
 Improves bowel function
 In CC it is safe and improves recovery
 Class IIb recommendation , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 PATIENT ENGAGEMENT TOOLS
 education and counseling
 Information platforms to reduce fear and anxiety
 Class IIa recommendation , level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 PREHABILITATION
 Increase the functional capacity of the patient to withstand the stress of surgery
 Exercise improves:
 sympathetic response
 insulin sensitivity
 Decreases body fat
 3-4 weeks prior to surgery

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Pre-operative strategies
 SMOKING AND CONSUMPTION OF ALCOHOLIC BEVERAGES
 Increase the risk of post-surgical complications
 1 month of abstinence prior to surgery have proven to improve the results of surgery
 Class I recommendation, level C-LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Intraoperative strategies
 REDUCTION OF QX SITE INFECTIONS
 Use of topical nasal antibiotics to eradicate
colonization of staphylococci
 18-30% of px carry S. aureus , conferring a 3-
fold increased risk of qx site infection and
bacteremia.  Mupirocin
 Use of cephalosporins 60 min prior to surgery
and continue 48 hrs after CC
 Cleaning the area refers to the advantage of
waxing over shaving
 Bath with chlorhexidine reduces risk of local
infection

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Intraoperative strategies
 HYPERTHERMIA
 Temp greater than 37.9 degrees is associated with neurological deficit, infection and kidney
injury
 Avoid hyperthermia in the first 24 hours post qx
 Association 4 to 6 weeks.
 Class III recommendation, BR level

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Intraoperative strategies
 RIGID STERNAL FIXATION
 Usual closure of the sternotomy with cerclage
 The use of a rigid plate is associated with fewer complications, pain, and improved function.
 Rigid fixation offers advantages over cerclage.
 Recommendation (class IIA, level BR)

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Intraoperative strategies
 TRANEXAMIC ACID
 Bleeding in CC is common.
 Easily accessible, low-risk, low-cost drug
 It was possible to reduce the total of transfusions and major hemorrhages with the use of
tramexamic acid
 At high doses risk of seizures
 Maximum dose of 100 mg/kg
 Class I recommendation, level A

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 GLYCEMIC CONTROL
 Better glycemic control = better postqx results and fewer complications
 Glucose morbidity is associated with glucose toxicity
 Increased oxidative stress
 Prothrombotic and inflammatory effect
 Class I recommendation, BR level

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 INSULIN INFUSION
 Treating hyperglycemia of 160-180 mg/dl is associated with a better post qx outcome
 Hypoglycemia should be avoided
 Accepted range 80-110 mg/dl
 Class IIa recommendation , level B-NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 PAIN MANAGEMENT
 Opioid use is associated with multiple adverse effects
 NSAIDs are associated with renal dysfunction after CHD
 COX -2 inhibitors are associated with increased thrombotic risk
 The safest pain reliever is paracetamol
 Tramadol has a dual effect, with a high risk of delirium.
 Pregabalin 1 hour prior to CC reduces pain
 Dexmedetomidine is associated with a lower risk of delirium
 Class I recommendation, level B-NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 SYSTEMATIC ASSESSMENT OF DELIRIUM
 Happens at up to 50% CC px
 There is no established pharmacological treatment
 Non-pharmacological strategies
 There is no evidence on the use of antipsychotics for prophylaxis
 Class I recommendation, level B-NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 PERSISTENT HYPOTHERMIA
 Inability to maintain >36 degrees C at 6 hours post CC
 It is associated with a higher risk of bleeding, infection and hospital stay
 Prevention of hypothermia
 Evidence class I, level B NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 PROBE PERMEABILITY
 Up to 36% of drains may be obstructed
 Clogged drains promote local inflammatory reaction
 Increased risk of pleural and pericardial effusion and AF
 There is no defined time to determine drain removal
 Evaluate until presence of spontaneous serous drainage.
 Unclogging drains is not recommended.
 Class I recommendation, level B NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 THROMBOPROPHYLAXIS
 PE and deep vein thrombosis are a constant risk after CHD
 Benefit of mechanical thromboprophylaxis
 Thromboprophylaxis should be considered daily
 Class IIa recommendation , level C LD

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 EXTUBATION STRATEGIES
 AMV is associated with longer hospitalization time , higher morbidity and mortality, and higher
cost
 Increased risk of pneumonia and dysphagia
 Early extubation is safe
 Extubation is recommended within the first 6 hours.
 Class IIa recommendation , level B NR

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 ACUTE KIDNEY DAMAGE
 AKI appears in up to 22 to 36% of CCs
 Urinary biomarkers can identify the lesion in the first hour
 Metalloproteinase inhibitory tissue factor 2 and insulin-like growth factor type 1
 Avoid nephrotoxic agents, monitor urine volume and creatitin serica
 Class IIa recommendation , BR level

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 Post operative strategies
 LIQUID THERAPY
 goal directed
 Blood pressure, cardiac output, SO2, lactate, urine output
 Class I recommendation, BR level

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.
 OTHER STRATEGIES
 ANEMIA
 RENAL OXYGENATION
 LUNG PROTECTION IN MECHANICAL SUPPORT
 EARLY ENTERAL FEEDING
 EARLY MOBILIZATION

Engelman D. Guidelines for perioperative care in cardiac surgery . JAMA Surg . 2019:154:755-766.