medigraphic.com
ISSN 1527-3172 (Electronic)

2021, Number 3-4

<< Back Next >>

MEDICC Review 2021; 23 (3-4)

Improved Recovery Protocols in Cardiac Surgery: A Systematic Review and Meta-Analysis of Observational and Quasi-Experimental Studies

Agüero-Martínez MO, Tapia-Figueroa VM, Hidalgo-Costa T

Language: English
References: 62
Page: 46-53
PDF size: 1080.73 Kb.


ABSTRACT

INTRODUCTION Improved recovery protocols were implemented in surgical specialties over the last decade, which decreased anesthetic and surgical stress and the incidence of perioperative complications. However, these recovery protocols were introduced more slowly for cardiac surgeries. The most frequent complications in cardiac surgery are related to patient clinical status and the characteristics of the surgical procedures involved, which are becoming more varied and complex every day. The first version of the enhanced recovery program for cardiac surgery was published in 2019, but its recommendations were based on only a few studies, and scant research has evaluated its implementation. Randomized and controlled clinical trials for these protocols are scarce, so research that summarizes the results of studies with other methodological designs are useful in demonstrating their benefits in cardiovascular surgery services in Cuba and in other limited-resource settings.
OBJECTIVE Estimate the effectiveness of improved recovery protocols in the perioperative evolution of patients undergoing cardiac surgery.
METHODS We performed a systematic review and meta-analysis according to the guidelines of manual 5.1.0 for reviews of the Cochrane library. We included observational and quasi-experimental studies published from January 2015 through May 2020 that compared enhanced recovery protocols with conventional treatments in patients older than 18 years, and used a quality score to evaluate them. We used the following sources: the Cochrane Library, PubMed, LILACS, SciELO, EBSCO, Google Scholar, Web of Science, Clinical Key, ResearchGate and HINARI. The following keywords were used for the database searches in English: ERAS, protocols and cardiac surgery, enhanced recovery after cardiac surgery, ERACS, clinical pathway recovery and cardiac surgery, perioperative care and cardiac surgery. We used the following search terms for databases in Spanish: protocolos de recuperación precoz and cirugía cardiaca, protocolos de recuperación mejorada and cirugía cardiaca, cuidados perioperatorios and cirugía cardiaca, programas de recuperación precoz and cirugía cardiovascular. Methodological quality of included investigations was evaluated using the surgical research methodology scale. Meta-analyses were performed for perioperative complications, intensive care unit and hospital stays, and hospital readmission within 30 days of surgery. We calculated effect sizes of the interventions and the corresponding 95% confidence intervals. We used mean differences and confidence intervals for continuous variables, and for qualitative variables we calculated relative risk (RR). Random effects analysis was used. Heterogeneity of the studies was assessed using the Q statistic and the I2 statistic.
RESULTS We selected 15 studies (a total of 5059 patients: study group, n = 1706; control group, n = 3353). The average quality score for the 15 articles included was 18.9 (out of a maximum of 36 according to the scale) and 66.6% had a score ≥18. With improved recovery protocols in cardiac surgery, the incidence of perioperative complications decreased (RR = 0.73; 95% CI 0.52–0.98) as did hospital readmission within 30 days after surgery (RR = 0.51; 95% CI 95% CI: 0.31–0.86). Differences in extubation time, hospital stay and length of stay in intensive care units were less marked, but always favored the group in which the enhanced protocols were implemented.
CONCLUSIONS Improved recovery protocols in cardiac surgery increase quality of care evidenced by reductions in perioperative complications and decreased incidence of hospital readmission in the month following surgery.


REFERENCES

  1. Pajares MA, Margarit JA, García-Camacho C,García-Suárez J, Mateo E, Castaño M, et al.DOCUMENTO DE CONSENSO Vía clínica derecuperación intensifi cada en cirugía cardiaca.Documento de consenso de la Sociedad Españolade Anestesiología, Reanimación y Terapéuticadel Dolor (SEDAR), la Sociedad Españolade Cirugía Cardiovascular y Endovascular (SECCE)y la Asociación Española de Perfusionistas(AEP). Rev Esp Anestesiol Reanim [Internet]. 2021 Apr [cited 2021 May 2];68(4):183–231.Available at: https://doi.org/10.1016/j.redar.2020.11.005. Spanish, English.

  2. Agüero Martínez MO. Protocolos de recuperaciónmejorada en cirugía cardiaca: aspectosesenciales de la evaluación y el apoyo nutricionalperioperatorio. Rev Cub Anest Rean [Internet].2019 May–Aug [cited 2019 Aug 5];18(2):e496.Available at: http://www.revanestesia.sld.cu/index.php/anestRean/article/view/496/816.Spanish.

  3. Agüero Martínez MO. Protocolos de recuperaciónprecoz en cirugía cardiaca. ¿Utopía orealidad? Rev Cub Anest Rean [Internet]. 2018May–Aug [cited 2018 Dec 26];17(2):42–52.Available at: http://www.revanestesia.sld.cu/index.php/anestRean/article/view/415/426.Spanish.

  4. Ljungqvist O, Young-Fadok T, Demartines N. Thehistory of Enhanced Recovery After Surgery andthe ERAS Society. J Laparoendosc Adv SurgTech. 2017 Sep;27(9):860–2.

  5. Melnyk M, Casey RG, Black P, Koupparis AJ.Enhanced Recovery After Surgery (ERAS)protocols: time to change practice? Can UrolAssoc J [Internet]. 2011 Oct [cited 2018 Jan13];5(5):342–8. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/22031616/

  6. Senturk J, Kristo G, Gold J, Bleday R, WhangE. The development of Enhanced Recovery AfterSurgery across surgical specialties. J LaparoendoscAdv Surg Tech A. 2017 Sep;27(9):863–70.

  7. Lau CSM, Chanberlain RS. Enhanced recoveryafter surgery programs improve patient outcomesand recovery: a meta-analysis. WorldJ Surg [Internet]. 2017 Apr [cited 2018 Jan13];41(4):899–913. Available at: https://doi.org/10.1007%2Fs00268-016-3807-4

  8. Scarci M, Solli P, Bedetti B. Enhanced recoverypathway for thoracic surgery in the UK. JThorac Dis [Internet]. 2016 Feb [cited 2018Jan 11];8(Suppl 1):S78–83. Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26941974/

  9. Lujungqvist O, Thanh NX, Nelson G. ERASvalued-based surgery. Review article. J SurgOncol [Internet]. 2017 Oct [cited 2018 Jan13];116(5):608–12. Available at: https://doi.org/10.1002/jso.24820

  10. Manso M, Schemelz J, Aloia T. ERAS- Anticipatedoutcomes and realistic goals. J SurgOncol [Internet]. 2017 Oct 1 [cited 2018 Jan13];116(5)570–7. Available at: https://doi.org/10.1002%2Fjso.24791

  11. Soeters PB. The Enhanced Recovery After Surgery(ERAS) program: benefi t and concerns. AmJ Clin Nutr [Internet]. 2017 Jul [cited 2018 Jan13];106(1):10–1. Available at: https://doi.g/10.3945%2Fajcn.117.159897

  12. Roulin D, Najjar P, Demartines N. EnhancedRecovery After Surgery implementation: fromplanning to success. J Laparoendosc Adv SurgTech A. 2017 Sep;27(9):876–9.

  13. Abeles A, Kwasnicki RM, Darzi A. Enhancedrecovery after surgery: Current researchinsights and future direction. World J GastrointestSurg [Internet]. 2017 Feb 27 [cited 2018Jan 13];9(2):37–45. Available at: https://doi.org/10.4240%2Fwjgs.v9.i2.37

  14. Indraratna K. A proposed strategy for enhancedrecovery after cardiac surgery. SurgeryCurr Res [Internet]. 2017 Sep [cited 2018Jan 11];7(5 Suppl). Available at: https://doi.org/10.4172%2F2161-1076-C1-032

  15. Nanavati AJ, Prabhakar S. Enhanced RecoveryAfter Surgery: if you are not implementing it, whynot? Practical Gastroenterol Series [Internet].2016 Apr [cited 2018 Jan 13];151:46–56. Availableat: http://www.practicalgastro.com

  16. Agüero Martínez MO. Protocolos de recuperaciónprecoz en cirugía cardiaca. Evidenciasen la práctica clínica. In: Centro de EventosORTOP: ECIMED. Jornada Habana 500 y IIITaller Nacional de anestesia Obstétrica [Internet].Havana: ECIMED; 2019 [cited 2019 Nov1]. Available at: http://actasdecongreso.sld.cu/index.php?P=FullRecord&ID=2523. Spanish.

  17. Chaney MA. Intrathecal and epidural anesthesiaand analgesia for cardiac surgery. Anesth Analg.2006 Jan;102(1):45–64.

  18. Agüero Martínez MO. Métodos anestésicosmultimodales en el procedimiento quirúrgicode revascularización miocárdica sin circulaciónextracorpórea. Ensayo clínico aleatorizado ymeta-análisis [thesis] [Internet]. [Havana]: Universityof Medical Sciences of Havana, HermanosAmeijeiras Clinical Surgical Hospital; 2011[cited 2018 Jan 23]. 130 p. Available at: http://tesis.sld.cu/index.php?P=FullRecord&ID=306.Spanish.

  19. Tham YC, Tan Z, Tam ALW, Sharad SS, SinKYK, Ong KK. Improving on fast- track protocolfor post cardiac surgery patients. J CardiothoracSurg [Internet]. 2015 Dec 16 [cited 2018 Jan11];10(Suppl 1):A330. Available at: https://doi.org/10.1186%2F1749-8090-10-S1-A330

  20. Liu SS, Block BM, Wu CL. Effects of perioperativecentral neuraxial analgesia on outcome aftercoronary artery bypass surgery. A meta-analysis.Anesthesiology. 2004 Jul;101(1):153–61.

  21. Hejimans JH, Lancé MD. Fast track minimallyinvasive aortic valve surgery: patient selectionand optimizing. Eur Heart J Suppl [Internet].2017 Jan [cited 2018 Jan 6];19(Suppl A):A8–14.Available at: https://doi.org/10.1093/eurheartj/suw056

  22. Lena P, Balarac N, Lena D, De la Chapelle A,Arnulf JJ, Mihoubi A, et al. Fast-track anesthesiawith remifentanil and spinal analgesia for cardiacsurgery: the effect on pain control and qualityof recovery. J Cardiothorac Vasc Anesth. 2008Aug;22(4):536–42.

  23. Jakobsen CJ. High thoracic epidural in cardiacanesthesia: a review. Semin CardiothoracVasc Anesth [Internet]. 2015 Mar [cited 2018Jan 7];19(1):38–48. Available at: https://doi.org/10.1177%2F1089253214548764

  24. Moraes dos Santos L, Cavani Jorge Santos V,Cavani Jorge Santos SR, Sá Malbouisson LM.Intrathecal morphine plus general anesthesiain cardiac surgery: effects on pulmonary function,post-operative analgesia and plasmamorphine concentration. Clinics (Sao Paulo).2009;64(4):279–85.

  25. Yapici D, Ozer ZO, Atici S, Bilgin E, Doruk N, CinelI, et al. Postoperative effect of low-dose intrathecalmorphine in coronary artery bypass surgery. JCard Surg. 2008 Mar–Apr;23(2):140–5.

  26. Tenenbein PK, Debrouwere R, Maguire D,Duke PC, Muirhead B, Enns J, et al. Thoracicepidural analgesia improves pulmonary functionin patients undergoing cardiac surgery. Can JAnaesth. 2008 Jun;55(6):344–50.

  27. Zaouter C, Imbault J, Labrousse L, AbdelmoumenY, Coiffi c A, Colona G, et al. Association ofrobotic totally endoscopic coronary artery bypassgraft surgery associated with a preliminary cardiacenhanced recovery after surgery. J CardiothoracVasc Anesth. 2015 Dec;29(6):1489–97.

  28. Ender J, Borger MA, Scholz M, Funkat AK,Anwar N, Sommer M, et al. Cardiac surgery fasttracktreatment in a post anesthetic care unit.Anesthesiology. 2008 Jul;109(1):61–6.

  29. Tian GJ, Li DY, Dong YD, Peng YN, Liu P, WeiYK, et al. [Clinical effi cacy of enhanced recoveryafter surgery in atrial caval shunting for type ABudd-Chiari syndrome]. Zhonghua Wai Ke ZaZhi. 2017 Sep 1;55(9):671–7. Chinese.

  30. van der Kolk M, van den Boogaard M, Brugge-Speeman CT, Hol J, Noyez L. Development andimplementation of a clinical pathway for cardiacsurgery in the intensive care unit: effects on protocoladherence. J Eval Clin Pract [Internet]. 2017Dec [cited 2018 Jan 6];23(6):1289–98. Availableat: https://doi.org/10.1111%2Fjep.12778

  31. Hardman G, Bose A, Saunders H, Walker AH.Enhanced recovery in cardiac surgery. J CardiothoracSurg [Internet]. 2015 [cited 2018 Jan11];10(Suppl 1):A75. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693802/

  32. Anastasiadis K, Asterious C, Antonitsis P,Agiriadou H, Grosomannidis V, Kyparissa M, etal. Enhanced recovery after elective coronaryrevascularization surgery with minimal versusconventional extracorporeal circulation: a prospectiverandomized study. J Cardiothorac VascAnesth [Internet]. 2013 Oct [cited 2018 Jan11];27(5):859–64. Available at: https://linkinghub.elsevier.com/retrieve/pii/S1053-0770(13)00018-9

  33. Waite I, Deshpande R, Baghai M, Massey T,Wendler O, Greenwood S. Home-based preoperativerehabilitation (prehab) to improve physical function and reduce hospital length of stay forfrail patient undergoing coronary artery bypassgraft and valve surgery. J Cardiothorac Surg.2017 Oct 26;12(1):91.

  34. Morasch A. 1st ERACS Best Practices Symposium.The formati on of Enhanced Recovery AfterCardiac Surgery Society. Enhanced RecoveryAfter Cardiac Surgery Society [Internet]. 2017[cited 2018 Jan 14]. Available at: http://www.eracs.org

  35. Fleming IO, Garratt C, Guha R, Desai J, ChaubeyS, Wang Y, et al. Aggregation of marginal gains incardiac surgery: feasibility of a perioperative carebundle for enhanced recovery in cardiac surgicalpatient. J Cardiothorac Vasc Anesth [Internet].2016 Jun [cited 2018 Jan 14];30(3):665–70.Available at: https://linkinghub.elsevier.com/retrieve/pii/S1053-0770(16)00022-7

  36. Williams P. ERAS Cardiac Surgery Named Offi -cial Heart Surgery Representative for ERASSociety [Internet]. San Francisco: Businesswire;2018 Apr 12 [cited 2018 Sep 9]. Availableat: https://www.businesswire.com/news/home/20180412005503/en/ERAS-Cardiac-Surgery-Named-Offi cial-Heart-Surgery

  37. Engelman DT, Ben Ali W, Williams JB, PerraultLP, Reddy VS, Arora RC, et al. Guidelines forperioperative care in cardiac surgery: EnhancedRecovery After Surgery Society recommendations.JAMA Surg [Internet]. 2019 Aug 1 [cited2019 May 9];154(8):755–66. Available at: https://doi.org/10.1001%2Fjamasurg.2019.1153

  38. Ferreira González I, Urrutia G, Alonso-Coello P.Revisiones sistemáticas y meta-análisis: basesconceptuales e interpretación. Rev Esp Cardiol[Internet]. 2011 [cited 2018 May 16];64(8):688–96. Available at: http://www.revespcardiol.org/es/revisiones-sistematicas-metaanalisis-bases-conceptuales/articulo/90024424/. Spanish.

  39. Catalá LF, Tobías A, Roqué M. Conceptos básicosdel metanálisis en red. Atención Primaria [Internet].2014 [cited 2018 May 16];46(10):573–81. Availableat: http://www.sciencedirect.com/science/article/pii/S0212656714001218. Spanish.

  40. Agüero Martínez MO. Anestesia multimodal enCirugía cardiovascular. In: Protocolización dela asistencia médica en el Hospital HermanosAmeijeiras: resultados en los primeros 5 añosde aplicación. 1st ed. Havana: ECIMED; 2012.p. 103–9. Spanish.

  41. Guay J, Kopp S. Epidural analgesia for adultsundergoing cardiac surgery with or without cardiopulmonarybypass. Cochrane Database ofSyst Rev [Internet]. 2019 Mar 1 [cited 2019 Sep3];3(3):CD006715. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/30821845/

  42. Higgins JPT, Green S. Cochrane Handbook forSystematic Reviews of Interventions 5.1.0 [Internet].London: The Cochrane Collaboration; 2011[updated 2011 Mar; cited 2018 Mar 8]. Availableat: https://handbook-5-1.cochrane.org/

  43. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferredreporting items for systematic reviewsand meta-analyses: The PRISMA Statement.PLoS Med [Internet]. 2009 [cited 2017 Jan10];6(7):e1000097. Available at: www.prisma-statement.org/documents/PRISMA%202009%20checklist.pdf

  44. Hutton B, Catala-López F, Moher D. La extensiónde la declaración PRISMA para revisionessistemáticas que incorporan metaanálisis enred: PRISMA-NMA. Med Clin (Barc) [Internet].2016 [cited 2018 May 16]. Available at:http://www.elsevier.es/en/linksolver/ft/pii/S0025-7753(16)00151-2. Spanish.

  45. Moraga J, Manterola C, Cartes-Velásquez RA,Burgos ME, Aravena P, Urrutia S. Instruccionespara la utilización de la escala MINCIR para valorarcalidad metodológica de estudios de terapia.Int J Morphol. 2014 May;32(1):294–8. Spanish.

  46. Martinos C, Daliakopolous S, Tsakalakis C,Georgiu M, Moraitis S. The use of fast track protocolfor perioperative management of cardiacsurgery patients. Anesth Crit Care Open Access[Internet]. 2017 Jun 13 [cited 2018 Jan 7];8(2).Available at: https://doi.org/10.15406%2Fjaccoa.2017.08.00301

  47. Motwani SK, Yadav VK, Jhanwar S. EnhancedRecovery After Cardiac Surgery - A single tertiarycare centre experience in India. EC Anaesthesia.2019;5(4):97–105.

  48. Gimpel D, Shanbhag S, Srivastava T, MacLeodM, Conaglen P, Kerjiwal N, et al. Early dischargefrom intensive care after cardiac surgery is feasiblewith an adequate fast track, stepdown unit:Waikato Experience. Heart Lung Circ [Internet].2019 Dec [cited 2019 Aug 8];28(12):1888–95.Available at: https://linkinghub.elsevier.com/retrieve/pii/S1443-9506(18)31970-X

  49. Markham T, Wegner R, Hernández N, Lee JW,Choi W, Eltzschig HK, et al. Assessment ofa multimodal analgesia protocol to allow theimplementation of enhanced recovery after cardiacsurgery: Retrospective analysis of patientoutcomes. J Clin Anaesth [Internet]. 2019 May[cited 2019 Aug 9];54:76–80. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0952818018309747?via%3Dihub

  50. Williams JB, McConnell G, Allender JE, WoltzP, Kane K, Smith PK, et al. One-year resultsfrom the fi rst US-based enhanced recoveryafter cardiac surgery (ERAS Cardiac) program.J Thorac Cardiovasc Surg [Internet]. 2019 May[cited 2019 Aug 8];157(5):1881–88. Available at:https://linkinghub.elsevier.com/retrieve/pii/S0022-5223(18)33225-2

  51. Grant MC, Isada T, Ruzankin P, Whitman G,Lawton JS, Dodd-O J, et al. Results from anenhanced recovery program for cardiac surgery.J Thorac Cardiovasc Surg [Internet]. 2019 [cited2019 Aug 8];159(4):1393–1402. Available at:https://linkinghub.elsevier.com/retrieve/pii/S0022-5223(19)31136-5

  52. Zaouter C, Oses P, Assatourian S, Labrousse L,Remy A, Ouattara A. Reduced length of hospitalstay for cardiac surgery—implementing an optimizedperioperative pathway: prospective evaluationof an Enhanced Recovery After Surgeryprogram designed for mini-invasive aortic valvereplacement. J Cardiothorac Vasc Anesth [Internet].2019 Nov [cited 2019 Aug 8];33(11):3010–19. Available at: https://linkinghub.elsevier.com/retrieve/pii/S1053-0770(19)30462-8

  53. Varelmann D, Shook D, Buric D, Yadzchi F,Dinga Madou I, Morth K, et al. Enhanced recoveryafter cardiac surgery: fl uid balance andincidence of acute kidney injury. J CardiothoracVasc Anesth [Internet]. 2019 Sep [cited 2019 Nov14];33 Suppl 2:S140–68. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1053077019306548

  54. Zammert M, Buric D, Yazdchi F, Dinga MadouI, Manca C, Woo S, et al. The infl uence ofEnhanced Recovery After Cardiac Surgeryon 30-day readmission rate, hospital and ICUlength of stay. J Cardiothorac Vasc Anesth. 2019Sep;33 Suppl 2:S102.

  55. Kowalski S, Goldie D, Maguire D, Arora RC,Girling I, Fransoo R, et al. High spinal anesthesiacombined with general anesthesia versus generalanesthesia alone: a retrospective cohort studyin cardiac surgical patients. Acta Anaesth Belg.2019;70(2):63–70.

  56. Borys M, Żurek S, Kurowicki A, Horeczy B, BielinaB, Sejboth J, et al. Implementation of EnhancedRecovery After Surgery (ERAS) protocol in offpumpcoronary artery bypass graft surgery. Aprospective cohort feasibility study. AnaesthesiolIntensive Ther [Internet]. 2020 Jan [cited 2020Dec 1];52(1). Available at: https://www.termedia.pl/Implementation-of-Enhanced-Recovery-After-Surgery-ERAS-protocol-in-off-pump-coronary-artery-bypass-graft-surgery-r-nA-prospective-cohort-feasibility-study,118,39938,0,1.html

  57. Chen L, Zheng J, Kong D, Yang L. Effect ofEnhanced Recovery After Surgery protocol onpatients who underwent off-pump coronary arterybypass graft. Asian Nursing Res (Korean SocNurs Sci) [Internet]. 2020 Feb [cited 2020 Jan1];14(1):44–9. Available at: https://linkinghub.elsevier.com/retrieve/pii/S1976-1317(20)30004-9

  58. Schulte K, Antoniou A, Attia R. Does fast-trackrecovery improve outcomes in adult cardiac surgery?Ann Cardiol Vasc Med [Internet]. 2018 Dec[cited 2018 Dec 26];3:1012. Available at: https://www.researchgate.net/publication/330847247_Does_fast-track_recovery_improve_outcomes_in_adult_cardiac_surgery

  59. Wells GA, Shea B, O’Connell D, Peterson J,Welch V, Losos M, et al. The Newcastle-OttawaScale (NOS) for assessing the quality of nonrandomisedstudies in meta-analyses [Internet].Ottawa: The Ottawa Hospital Research Institute;2021 [cited 2021 Jan 2]. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

  60. von Elm E, Altman DG, Egger M, Pocock SJ,Gotzsche PC, Vandenbroucke JP. Declaraciónde la iniciativa STROBE (Strengthening theReporting of Observational studies in Epidemiology):directrices para la comunicación de estudiosobservacionales. Rev Esp Salud Pública.2008 May–Jun;22(3):251–9. Spanish.

  61. Wong WCW, Cheung CSK, Hart GJ. Developmentof a quality assessment tool for systematicreviews of observational studies (QATSO) of HIVprevalence in men having sex with men andassociated risk behaviours. Emerg Themes Epidemiol[Internet]. 2008 Nov 17 [cited 2018 May5];5:23. Available at: https://ete-online.biomedcentral.com/articles/10.1186/1742-7622-5-23

  62. Dagnino SJ. Intervalos de confi anza. RevChil Anest [Internet]. 2014 [cited 2021 May15];43(2):129–33. Available at: https://doi.org/10.25237/revchilanestv43n02.11




2020     |     www.medigraphic.com