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Selecting Elements for a Cardiac Enhanced Recovery Protocol

      The Executive Board membership of the Society for Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) read with great interest the review by Zaouter et al.
      • Zaouter C
      • Damphousse R
      • Moore A
      • et al.
      Elements not graded in the Cardiac Enhanced Recovery After Surgery Guidelines might improve postoperative outcome: A comprehensive narrative review [e-pub ahead of print].
      Their comparison of the various elements in published cardiac enhanced recovery protocols was thorough and comprehensive. It also revealed topics warranting further discussion and elaboration regarding the process that led to our Society's Guidelines, as well as how we envision their role within the development of a cardiac surgical enhanced recovery program.
      There were a number of reasons why a certain element or intervention may not have been included in our 2019 ERAS Cardiac Guidelines (22 recommendations: 9 level I, 9 level IIa, 2 level IIb, and 2 level III).
      • Engelman DT
      • Ben Ali W
      • Williams JB
      • et al.
      Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society Recommendations.
      Commonly, although it may have existed within the available literature at the time, there was insufficient evidence for proper grading within our defined methodology—an acknowledged challenge from the outset.
      • Noss C
      • Prusinkiewicz C
      • Nelson G
      • et al.
      Enhanced recovery for cardiac surgery.
      Such was the case regarding prevention of postoperative nausea/vomiting, goal-directed perfusion, regional anesthesia, and early removal of drains and lines. New data have since been published; many of these will be reconsidered and graded accordingly in future updates. For other elements, such as patient blood management, a well-established multisociety guideline was already in place. In this circumstance, an ERAS program should leverage its established infrastructure of teams, collaboration, education, and audit to ensure consistent application of these preexisting guidelines. Admittedly, ERAS Cardiac should strive to provide this differentiation and guidance with greater clarity.
      When applying our society's guidelines within the development of a cardiac ERAS protocol, we encourage the use of our listed elements as a starting point to open collaborative discussion, rather than as a rigid construct to dictate the boundaries of the conversation.
      • Salenger R
      • Morton-Bailey V
      • Grant M
      • et al.
      Cardiac enhanced recovery after surgery: A guide to team building and successful implementation.
      With this goal in mind, certain elements were purposefully worded in a broad, goal-based, and inclusive format. Perioperative multimodal analgesia and early extubation are such examples. The element grading in the Guidelines identifies the overall patient-care goal, while specifics regarding phase of care, techniques, medications, and algorithms are left to the discretion of each institution. This allows a local protocol to achieve outcome measures using interventions and strategies that are feasible and effective within their local environment.
      We encourage teams currently developing ERAS protocols to consider diverse sources when appraising their options for elements. Pertinent guidelines published by other societies, cardiac-appropriate elements from published noncardiac ERAS guidelines, and nonpublished conscientious care (eg, telehealth consults for rural patients) all can be considered. However, we wish to extend a word of caution. Achieving improved outcomes through an accumulation of marginal gains and synergies provided by bundling of elements is a foundational principle of enhanced recovery. An unfortunate corollary of this is the accepted limitation that certain elements within the bundle may be generating the majority of the benefitwhile others are along for the ride. Prospective randomized trials to determine the relative contribution of each component of a bundle is not likely to be an achievable objective. It would be impractical and contrary to the very purpose of bundling elements. Yet, this should not open the door for excessive limited-evidence interventions to be included as a matter of updated personal preferences, in which old dogma is replaced by new. A good rule is to ensure that ERAS protocols are constructed as much as possible with elements and interventions that meet the highest available standards of evidence-based medicine. At times there may be appropriate protocol components with preliminary evidence, indirect evidence, or a nonevidence-based physiologic/patient-centered justification. These can be included cautiously if they represent the minority and are not associated with high costs or increased risk to the patient. Neglecting to judiciously select the presence of limited-evidence interventions will risk failure of an ERAS program through poor acceptance, adherence, or lack of maximally improved outcomes.
      Enhanced recovery programs are iterative, a cycle of continuous feedback, improvement, refinement, and growth. Over time, new areas in perioperative patient care will emerge. The enhanced recovery community previously has recognized that the 2019 Guidelines were an important first step, not the final say.
      • Gregory AJ
      • Grant MC
      • Manning MW
      • et al.
      Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) recommendations: An important first step–but there is much work to be done.
      The path toward state-of-the-art optimization of enhanced patient care only will be achieved by global collaboration, with a multidisciplinary approach to program implementation, publication of results, critical appraisal, and integration of new knowledge.

      Conflict of Interest

      All of the authors are non-remunerated Executive Board Members of the ERAS® Cardiac Society, a non-profit organization. None of the authors have any conflicts to report. RCA additional disclosures:  Pfizer Canada Inc - Unrestricted educational grant. Mallinckrodt Pharmaceuticals, Abbott Nutrition and Edwards Lifesciences – Honoraria. KWL additional disclosures: Perfect Care Grant from The Duke Endowment ($1.11 MM), Medtronic Inc-Independent Quality Consulting and Data Safety Monitoring Board, Abiomed, Inc IMPACT Steering Committee.

      References

        • Zaouter C
        • Damphousse R
        • Moore A
        • et al.
        Elements not graded in the Cardiac Enhanced Recovery After Surgery Guidelines might improve postoperative outcome: A comprehensive narrative review [e-pub ahead of print].
        J Cardiothorac Vasc Anesth. 2021 Jan 21; https://doi.org/10.1053/j.jvca.2021.01.035.2
        • Engelman DT
        • Ben Ali W
        • Williams JB
        • et al.
        Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society Recommendations.
        JAMA Surg. 2019; 154: 755-766
        • Noss C
        • Prusinkiewicz C
        • Nelson G
        • et al.
        Enhanced recovery for cardiac surgery.
        J Cardiothorac Vasc Anesth. 2018; 32: 2760-2770
        • Salenger R
        • Morton-Bailey V
        • Grant M
        • et al.
        Cardiac enhanced recovery after surgery: A guide to team building and successful implementation.
        Semin Thorac Cardiovasc Surg. 2020; 32: 187-196
        • Gregory AJ
        • Grant MC
        • Manning MW
        • et al.
        Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) recommendations: An important first step–but there is much work to be done.
        J Cardiothorac Vasc Anesth. 2020; 34: 39-47

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