ERAS Cardiac is an evidence-based, multidisciplinary initiative to standardize perioperative care and promote faster recovery for cardiac surgery patients. It includes 22 interventions divided into pre, intra, and postoperative phases. Implementation of ERAS Cardiac protocols resulted in decreased length of stay, ICU hours, and complications, as well as increased patient satisfaction compared to conventional care. Standardizing key processes like preoperative education, intraoperative glycemic control, and multimodal analgesia through a team-based approach can successfully enhance recovery after cardiac surgery.
Jehowah's witnesses and blood conservation strategies by Dr.Minnu M. PanditraoMinnu Panditrao
dr. Mrs. Minnu M. Panditrao explains the problems faced by anesthesiologists in anesthetising the Jehowah's Witness patients because of their beliefs. Ina ddition she also discribes various strategies of Blood conservation.
Jehowah's witnesses and blood conservation strategies by Dr.Minnu M. PanditraoMinnu Panditrao
dr. Mrs. Minnu M. Panditrao explains the problems faced by anesthesiologists in anesthetising the Jehowah's Witness patients because of their beliefs. Ina ddition she also discribes various strategies of Blood conservation.
B. kim current cabg strategies and hybrid proceduresAlysia Smith
Betty S. Kim, MD, FACS presents on "Current CABG Strategies and Hybrid Procedures" for the March 4 -6, 2016 Cardiac and Thoracic Surgery Associates, Cardiovascular Summit at The Westin Riverfront Resort and Spa.
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
B. kim current cabg strategies and hybrid proceduresAlysia Smith
Betty S. Kim, MD, FACS presents on "Current CABG Strategies and Hybrid Procedures" for the March 4 -6, 2016 Cardiac and Thoracic Surgery Associates, Cardiovascular Summit at The Westin Riverfront Resort and Spa.
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
The implementation of an ERAS protocol for radical cystectomy reduces LOS, with no effect on early complication rates or 30-day readmission rates. This indicates that the protocol is safe for patients when compared to previous practices and is an effective means of reducing LOS.
PCI is one of the most common procedures in the US, and remain a cornerstone in the management of ischemic heart disease.
Historically, a large proportion of PCI procedures were performed during inpatient hospitalization, allowing for a significant amount of time for monitoring postprocedure to ensure procedural success & identify bleeding or vascular complications, as well as for initiating secondary prevention.
However, technological pharmacological and procedural innovations, as well as payer expectations and cost considerations, have led to a shorter length of stay postprocedure and obviate hospital admission.
Most non-acute MI PCIs performed in the US now are performed under an outpatient designation.
perioperative preparations in obstetrics and Gynecology.pptxEkramNasher
This PowerPoint describe all preparations that doctors follow during preparation obstetrical and Gynecological cases for operations and the important instructions which should be taken
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. ERAS-Cardiac
• evidence-based protocols for perioperative care leading to
improvements in clinical outcomes and cost saving
• multimodal, trans-disciplinary care improvement initiative to
promote recovery of patients undergoing cardiac surgery
• aim to reduce complications and promote an earlier return to
normal activities.
• reduction in overall complications and length of stay of up to
50% compared with conventional perioperative patient
management in populations having non-cardiac surgery
3. • ERAS Cardiac society - group of 16 cardiac surgeons,
anesthesiologists, and intensivists
• 22 potential interventions, divided into preoperative,
intraoperative, and postoperative phases of recovery.
www.erascardiac.org
4. PubMed, Excerpta Medica (Embase), Cochrane, the Agency for
Healthcare Research and Quality, and other selected databases
5.
6. The evolution and future of ACC/AHA clinical practice guidelines J Am Coll Cardiol. 2014;64:1373-84.
7. Preoperative Strategies
Measurement of Hemoglobin A1cfor Risk Stratification
• less than 6.5%, has been associated with significant decrease in
deep sternal wound infection, ischemic events, and other
complications
• achieve a hemoglobin A1c
level less than 7% in patients for whom this
is relevant
• approximately 25% of patients undergoing CS have hemoglobin A1c
levels greater than 7%, and 10% have undiagnosed diabetes
• recommend preoperative measurement of hemoglobin A1c
to assist with
risk stratification (class IIa, level C-LD)
8. Albumin
• Low serum albumin in patients undergoing CS - increased
risk of morbidity and mortality postoperatively
(independent of body mass index)
• Correlates with increased length of ventilation, acute
kidney injury (AKI), infection, longer length of stay, and
mortality
• preoperative albumin assessment before CS to assist with
risk stratification (class IIa, level C-LD)
9. Nutritional Deficiency
• oral nutritional supplementation has the greatest effect if
started 7 to 10 days preoperatively and has been
associated with a reduction in the prevalence of infectious
complications.
• With a serum albumin level less than 3.0 g/dL, 7 to 10
days worth of intensive nutrition therapy may improve
outcomes.
• may not be feasible in urgent or emergency settings
• (class IIa, level C-LD)
10. Clear Liquids Before GA
• nonalcoholic clear fluids can be safely given up to 2 hours
before the induction of anesthesia,
• light meal can be given up to 6 hours before elective
procedures requiring general anesthesia.
• Aspiration pneumonitis has not been reported, although
this potential remains in patients undergoing CS who have
delayed gastric emptying owing to diabetes mellitus,
• (class IIb, level C-LD).
11. Preoperative Carbohydrate Loading
• A carbohydrate drink (a 12-ounce clear beverage or a 24-g complex
carbohydrate beverage) 2 hours preoperatively
• reduces insulin resistance
• Reduces tissue glycosylation,
• improves postoperative glucose control,
• enhances return of gut function.
• found to be safe and improved cardiac function immediately after
cardiopulmonary bypass.
• (class IIb, level C-LD)
12. Patient Education
• explanation of procedures and goals that may help reduce
perioperative fear, fatigue, and discomfort and enhance
recovery and early discharge
• software applications can engage patients, promote
compliance, and capture patient-reported outcome
measures.
• designed to increase preventive care and encourage
patients to perform physical exercise.
• (class IIa, level C-LD)
13. Prehabilitation
• enables patients to withstand the stress of surgery by augmenting
functional capacity.
• Preoperative exercise decreases sympathetic overreactivity, improves
insulin sensitivity, and increases the ratio of lean body mass to body fat.
• improves physical and psychological readiness for surgery, reduces
postoperative complications and the length of stay, and improves the
transition from the hospital to the community
• include education, nutritional optimization, exercise training, social support,
and anxiety reduction,
• Recommend 3-4 weeks of prehabilitation in the context of ERAS
14. Smoking and Alcohol
• risk factors for postoperative complications and present
another opportunity for preoperative intervention.
• associated with respiratory, wound, bleeding, metabolic,
and infectious complications
• Recommend smoking cessation and hazardous alcohol
consumption for 1 month
• may not be feasible in urgent or emergency settings
(class I, level C-LD).
16. Intraoperative Strategies
• weight-based cephalosporins administered fewer than 60 minutes before the
skin incision and continued for 48 hours after completion of CS
• Redosing required if surgery > 4 hours
• meta-analysis of skin preparation and depilation protocols indicates that
clipping is preferred to shaving
• Clipping using electric clippers should occur close to the time of surgery.
• A preoperative shower with chlorhexidine has only been demonstrated to
reduce bacterial counts in the wound and is not associated with significant
levels of efficacy.
• Postoperative measures including sterile dressing removal within 48 hours and
daily incision washing with chlorhexidine are potentially beneficial
American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59-74.
17. Hyperthermia
• on cardiopulmonary bypass (CPB), hyperthermia (core
temperature >37.9°C) is associated with cognitive deficits,
infection, and renal dysfunction.
• hyperthermia within 24 hours after coronary artery bypass
grafting - associated with cognitive dysfunction at 4 to 6
weeks
• Rewarming on CPB should be combined with continuous
surface warming.
• (class III, level B-R).
Rewarming temperature during cardiopulmonary bypass and acute kidney injury: a multicenter analysis. Ann Thorac Surg. 2016;101(5):1655-1662.
18. Rigid Sternal Fixation
• Traditional wire cerclage achieves approximation and
compression but does not eliminate side-by-side
movement
Vs
Ann Thorac Surg. 2018;105(5):1344-1350.
19. • 2 multicenter randomized studies - significantly better sternal healing,
fewer sternal complications, and no additional cost compared with
wire cerclage at 6 months after surgery.
• significantly less pain, better upper-extremity function, and improved
quality-of-life scores, with no difference in total 90-day cost.
• Limitations - sample size designed to test the primary end point of
improved sternal healing but not the secondary end points of pain and
function
• especially considered in individuals at high risk, such as those with a
high BMI, previous chest wall radiation, severe COPD, or steroid use.
• (class IIa, level B-R).
Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg. 2017;153(4):
20. Tranexamic Acid or EACA
• intraoperative blood scavenging, monitoring of the coagulation
system, and data-driven algorithms for appropriate transfusion
practices
• total blood products transfused, and major hemorrhage or
tamponade requiring re-operation were reduced using tranexamic
acid.
• Higher dosages, however, appear to be associated with seizures.
• A maximum total dose of 100 mg/kg is recommended.
• (class I, level A).
Eur J Cardiothorac Surg. 2018;53(1):79-111
21. Postoperative Strategies
• Perioperative Glycemic Control
• Interventions to improve glycemic control are known to
improve outcomes.
• Epidural analgesia during CS has been shown to reduce
hyperglycemia incidence.
• hyperglycemia morbidity is multifactorial and attributed to
glucose toxicity, increased oxidative stress, prothrombotic
effects, and inflammation
• (class I, level B-R)
22. Insulin Infusion
• Treatment of hyperglycemia (glucose >160-180 mg/dL)with
an insulin infusion for the patient undergoing CS may be
associated with improved perioperative glycemic control
• Postoperative hypoglycemia should be avoided, especially
in patients with a tight blood glucose target range (80-110
mg/dL)
• Randomized clinical trials support insulin infusion protocols
to treat hyperglycemia perioperatively;
• (class IIa, level B-NR)
23. Pain Management
• Opioids - multiple adverse effects, including sedation, respiratory depression,
nausea, vomiting, and ileus.
• multimodal opioid-sparing approaches - additive or synergistic effects of
different types of analgesics, permitting lower opioid doses
• NSAIDs are associated with renal dysfunction after CS
• Selective COX-2 inhibition - risk of thromboembolic events
• The safest nonopioid analgesic may be acetaminophen.Intravenous
acetaminophen may be better absorbed until gut function has recovered
postoperatively.
• when added to opioids, acetaminophen produces superior analgesia, an
opioid-sparing effect, and independent antiemetic actions.
24. • Tramadol - dual opioid and nonopioid effects but with a high delirium risk.
• produces a 25% decrease in morphine consumption, decreased pain
scores, and improved patient comfort postoperatively.
• Pregabalin - decreases opioid consumption - used in postoperative
multimodal analgesia.Pregabalin given 1 hour before surgery and for 2
postoperative days improves pain scores compared with placebo.
• Dexmedetomidine, an intravenous α-2 agonist, reduces opioid
requirements and reduces AKI
• reduced all-cause mortality at 30 days with a lower incidence of
postoperative delirium and shorter intubation times.
• Ketamine - favorable hemodynamic profile, minimal respiratory depression,
analgesic properties.
25. • acute confusional state characterized by fluctuating mental status, inattention, and
either disorganized thinking or altered level of consciousness
• occurs in approximately 50% of patients after CS.
• associated with reduced in hospital and long-term survival, freedom from hospital
readmission, and cognitive and functional recovery.
• Early delirium detection is essential to determine the underlying cause (ie, pain,
hypoxemia, low cardiac output, and sepsis) and initiate appropriate treatment
• The perioperative team should consider routine delirium monitoring at least once
per nursing shift.
• Nonpharmacologic strategies are a first-line component of management.There is
no evidence that prophylactic antipsychotic use (eg, haloperidol) reduces delirium.
Postoperative Delirium Screening
26. Persistent Hypothermia
• failure to return to or maintain normothermia (>36°C) 2 to 5 hours
after an intensive care unit (ICU) admission
• associated with increased bleeding, infection, prolonged hospital stay,
and death.
• prevention by
• forced-air warming blankets,
• raising the ambient room temperature,
• warming irrigation and intravenous fluids in the early
postoperative period
27. Chest Tube Patency
• Drains used to evacuate shed mediastinal blood are prone
to clogging with clotted blood in up to 36% of patients.
• shed mediastinal blood can necessitate re-interventions for
tamponade or hemothorax.
• hemolyzed blood promotes an oxidative inflammatory
process that may further cause pleural and pericardial
effusions and trigger postoperative atrial fibrillation
• Chest tube manipulation strategies such as stripping or
milking or of questionable safety and efficacy
Pericardial blood as a trigger for postoperative atrial fibrillation after cardiac surgery. Ann Thorac Surg. 2018;105(1):321-328.
28. • chest-tube stripping has been shown to be ineffective and
potentially harmful.
• Breaking the sterile field to access the inside of chest
tubes and use a smaller tube to suction the clot out can be
dangerous - increases infection risk and can potentially
damage internal structures.
29. • active chest tube clearance methods can be used to
prevent occlusion without breaking the sterile field.
• Reduces subsequent need for interventions to treat
retained blood compared with conventional chest tube
drainage in 5 non-randomized clinical trials of CS.
Active clearance of chest drainage catheters reduces retained blood. J Thorac Cardiovasc Surg. 2016;151(3)
30.
31.
32. Chemical Thromboprophylaxis
Vascular thrombotic events include both DVT and PE - represent potentially
preventable complications.
Patients remain hypercoagulable after CS, increasing vascular thrombotic event risk.
mechanical thromboprophylaxis: compression stockings and/or intermittent
pneumatic compression during hospitalization or until they are adequately mobile
Prophylactic anticoagulation for vascular thrombotic events should be considered on
the first post- operative day and daily thereafter
pharmacological prophylaxis should be used as soon as satisfactory hemostasis
has been achieved (most commonly on postoperative day 1 through discharge)
(class IIa, level C-LD)
European guidelines on perioperative venous thromboembolism prophylaxis: cardiovascular and thoracic surgery. Eur J Anaesthesiol. 2018
33. Extubation Strategies
Prolonged mechanical ventilation - associated with longer
hospitalization, higher morbidity, mortality, and increased costs.
associated with both ventilator-associated pneumonia and
significant dysphagia
Early extubation, within 6 hours of ICU arrival, can be achieved
with time-directed extubation protocols and low-dose opioid
anesthesia.
strategies to ensure extubation within 6 hours of surgery are
recommended (class IIa, level B-NR)
Early extubation without increased adverse events in high-risk cardiac surgical patients. Ann Thorac Surg. 2019;107(2):453-459
34. Kidney Stress and Acute Kidney Injury
• AKI complicates 22% to 36% of cardiac surgical
procedures, doubling total hospital costs.
• Urinary biomarkers (tissue inhibitor of metalloproteinases-
2 and insulin like growth factor binding protein 7) can
identify patients as early as 1 hour after CPB who are at
increased risk of developing AKI.
• randomized clinical trial - patients with positive urinary
biomarkers who were assigned to an intervention
algorithm had reductions in subsequent AKI
Biomarker-guided intervention to prevent acute kidney injury after major surgery: Ann Surg. 2018;267(6
35. • algorithm included avoiding nephrotoxic agents,
discontinuing ACE inhibitors and ARBs for 48 hours
• monitoring of creatinine and urine output, avoiding
hyperglycemia and radiocontrast agents, and close
monitoring to optimize volume status and hemodynamic
parameters.
• biomarkers are recommended for early identification of
patients at risk and to guide an intervention strategy to
reduce AKI (class IIa, level B-R)
36. Goal-Directed Fluid Therapy
• monitoring techniques to guide clinicians with
administering fluids, vasopressors, and inotropes to avoid
hypotension and low cardiac output.
• Quantified goals include blood pressure, cardiac index,
systemic venous oxygen saturation, lactates and urine
output.
• reduced complication rates and length of stay
• (class I, level B-R).
37. Ungraded ERAS elements
• Investigation and treatment of preoperative cause of
anaemia
• Impaired renal oxygenation has been demonstrated during
CPB and is ameliorated by an increase in CPB flow.
• comprehensive protective lung ventilation strategy.
• Early postoperative enteral feeding and mobilization
J Cardiovasc Thorac Res. 2017;9(4):221-228.
38.
39.
40. Methods
Standardised processes:
(1) preoperative patient education,
(2) carbohydrate loading 2 hours before general anesthesia,
(3) multimodal opioid-sparing analgesia,
(4) goal-directed perioperative insulin infusion, and
(5) a rigorous bowel regimen.
41. • pre- (N = 489) with the post- (N = 443) ERAS Cardiac
groups
• median postoperative length of stay was decreased from 7
to 6 days
• Total ICU hours were decreased from a mean of 43 to
28 hours.
• GI complications were 6.8% pre-ERAS versus 3.6% post-
ERAS implementation
• Opioid use was reduced by a mean of 8 mg of morphine
equivalents per patient in the first 24 hours postoperatively
42. • Reintubation rate and intensive care unit readmission rate
were reduced by 1.2% and 1.5%, respectively
• Patient satisfaction was 86.3% pre-ERAS versus 91.8%
post-ERAS
• Cardiac implementation and work culture domain scores
revealed increases in satisfaction across all measured
indices, including patient focus, culture, and engagement.
43. Conclusion
• fast-track project to improve outcomes was first initiated by
bundling perioperative treatments.
• initiated in the 1990s by a group of academic surgeons to
improve peri-operative care for patients receiving colorectal
care - now practiced in most fields of surgery.
• In CS - aims to develop protocols to decrease unnecessary
variation and improve quality, safety, and value for patients.
• a broad-based, multidisciplinary approach is imperative for
success.