Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients.
OBJECTIVE
The aim of this pilot study was to assess the feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS).


METHODS
A prospective, observational study.


METHODS
A major urban teaching and university hospital and tertiary referral center.


METHODS
The study included 53 patients undergoing cardiac surgery before implementation of an ERACS protocol (pre-ERACS group) and 52 patients undergoing cardiac surgery after implementation of an ERACS protocol (ERACS group).


METHODS
Based on recommendations from a consensus review in colorectal surgery, the following enhanced recovery perioperative care bundle was applied: detailed preoperative information, avoidance of prolonged fasting periods preoperatively, preoperative carbohydrate beverages, optimization of analgesia with avoidance of long-acting opioids, prevention of postoperative nausea and vomiting, early enteral nutrition postoperatively, and early mobilization.


RESULTS
The authors hypothesized that length of hospital stay would be reduced with ERACS. Secondary outcome variables included a composite of postoperative complications and pain scores. Whereas the length of stay in the group of patients receiving the bundle of enhanced recovery interventions remained unchanged compared with the non-ERACS group, there was a statistically significant reduction in the number of patients in the ERACS group presenting with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, postoperative myocardial infarction, and death). In addition, postoperative pain scores were improved significantly in the ERACS group.


CONCLUSIONS
This pilot study demonstrated that ERACS is feasible and has the potential for improved postoperative morbidity after cardiac surgery. A larger multicenter quality improvement study implementing perioperative care bundles would be the next step to further assess outcomes in ERACS patients.
Anaesthesia.
Ian O
IO
Fleming
Anaesthesia.
Claire
C
Garratt
Anaesthesia.
Ranj
R
Guha
†Cardiac Surgery, King's College Hospital NHS Foundation Trust, London, UK.
Jatin
J
Desai
†Cardiac Surgery, King's College Hospital NHS Foundation Trust, London, UK.
Sanjay
S
Chaubey
‡Division of Health and Social Care Research, King's College London, London, UK.
Yanzhong
Y
Wang
Anaesthesia; §Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
Sara
S
Leonard
Anaesthesia. Electronic address: gudrun.kunst@kcl.ac.uk.
Gudrun
G
Kunst
D000368:Aged; D006348:Cardiac Surgical Procedures; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000503:physiopathology; D019990:Perioperative Care; D010865:Pilot Projects; D011446:Prospective Studies; D058996:Quality Improvement; D020127:Recovery of Function
cardiac surgery; enhanced recovery; perioperative quality improvement bundles; postoperative morbidity