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Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching

Published:October 13, 2022DOI:https://doi.org/10.1053/j.jvca.2022.10.009

      Objective

      To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG).

      Design

      A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS.

      Setting

      At a tertiary care teaching hospital.

      Participants

      A total of 1,012 patients undergoing urgent or emergent CABG—346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk.

      Interventions

      None.

      Measurements and Main Results

      Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods.

      Conclusions

      Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

      Key Words

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      References

        • Ljungqvist O
        • Scott M
        • Fearon KC.
        Enhanced recovery after surgery: A review.
        JAMA Surg. 2017; 152: 292-298
        • Markham T
        • Wegner R
        • Hernandez N
        • et al.
        Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: Retrospective analysis of patient outcomes.
        J Clin Anesth. 2019; 54: 76-80
        • Zhang Y
        • Chong JH
        • Harky A.
        Enhanced recovery after cardiac surgery and its impact on outcomes: A systematic review.
        Perfusion. 2022; 37: 162-174
        • Hardman G
        • Bose A
        • Saunders H
        • et al.
        Enhanced recovery in cardiac surgery.
        J Cardiothorac Surg. 2015; 10: A75
        • Schumer EM
        • Chaney JH
        • Trivedi JR
        • et al.
        Emergency coronary artery bypass grafting: Indications and outcomes from 2003 through 2013.
        Tex Heart Inst J. 2016; 43: 214-219
        • Rastan AJ
        • Eckenstein JI
        • Hentschel B
        • et al.
        Emergency coronary artery bypass graft surgery for acute coronary syndrome: beating heart versus conventional cardioplegic arrest strategies.
        Circulation. 2006; 114: 1477-1485
        • Mohammad WA
        • Ashraf Z
        • Sayed HF.
        Urgent versus elective coronary artery bypass grafting in acute coronary syndrome.
        J Egypt Soc Cardiothorac Surg. 2018; 26: 17-23
        • Hung DQ
        • Minh NT
        • Vo H-L
        • et al.
        Impact of pre-, intra- and post-operative parameters on in-hospital mortality in patients undergoing emergency coronary artery bypass grafting: A scarce single-center experience in resource-scarce setting.
        Vasc Health Risk Manag. 2021; 17: 211-226
        • Axelsson TA
        • Mennander A
        • Malmberg M
        • et al.
        Is emergency and salvage coronary artery bypass grafting justified? The Nordic Emergency/Salvage coronary artery bypass grafting study.
        Eur J Cardiothorac Surg. 2016; 49: 1451-1456
        • Lawton JS
        • Tamis-Holland JE
        • Bangalore S
        • et al.
        2021 ACC/AHA/SCAI Guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol 2022;79:1547].
        J Am Coll Cardiol. 2022; 79: e21-e129
        • Levi A
        • Kornowski R
        • Vaduganathan M
        • et al.
        Incidence, predictors, and outcomes of failed primary percutaneous coronary intervention – a 10-year contemporary experience.
        Coronary Artery Disease. 2014; 25: 145-151
        • Engelman DT
        • Walid BA
        • Williams JB
        • et al.
        Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations.
        JAMA Surg. 2019; 154: 755-766
        • Sutton TS
        • McKay RG
        • Mather J
        • et al.
        Enhanced recovery after surgery is associated with improved outcomes and reduced racial and ethnic disparities after isolated coronary artery bypass surgery: A retrospective analysis with propensity score matching.
        J Cardiothor Vasc Anesth. 2022; 36: 2418-2431
      1. The Society of Thoracic Surgeons. STS adult cardiac surgery database data specifications: Version 4.20.2. Available at: https://www.sts.org/registries-research-center/sts-national-database/adult-cardiac-surgery-database/data-collection. Accessed April 7, 2022.

      2. Lexicomp. Available at: https://online.lexi.com/lco/action/login. Accessed April 7, 2022.

        • Mascha EJ
        • Sessler DI.
        Segmented regression and difference-in-difference methods: Assessing the impact of systemic changes in health care.
        Anesth Analg. 2019; 129: 618-633
        • Williams JB
        • McConnell G
        • Allender JE
        • et al.
        One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.
        J Cardiovasc Surg. 2019; 157: 1881-1887
      3. NCSS, LLC. PASS 2022 - Power analysis and sample size software. Available at: https:/www.ncss.com/software/pass. Accessed August, 16, 2022.

        • Brinck ECV
        • Tiippana E
        • Heesen M
        • et al.
        Perioperative intravenous ketamine for acute postoperative pain in adults.
        Cochrane Database Syst Rev. 2018; 12CD012033
        • Himmelseher S
        • Durieux ME.
        Ketamine for perioperative pain management.
        Anesthesiology. 2005; 102: 211-220
        • Simpson JC
        • Bao X
        • Agarwala A.
        Pain management in enhanced recovery after surgery (ERAS) protocols.
        Clin Colon Rectal Surg. 2019; 32: 121-128
        • Kelava M
        • Alfirevic A
        • Bustamante S
        • et al.
        Regional anesthesia in cardiac surgery: An overview of fascial plane chest wall blocks.
        Anesth Analg. 2020; 131: 127-135
        • Ranucci M
        • Johnson I
        • Willcox T
        • et al.
        Goal-directed perfusion to reduce acute kidney injury: A randomized trial.
        J Thorac Cardiovasc Surg. 2018; 156 (e2): 1918-1927
        • Srey R
        • Rance G
        • Shapeton AD
        • et al.
        A quick reference tool for goal-directed perfusion in cardiac surgery.
        J Extra Corpor Technol. 2019; 51: 172-174
        • Guinn NR
        • Schwartz J
        • Arora RC
        • et al.
        Perioperative quality initiative and the enhanced recovery after surgery-Cardiac Society consensus statement on the management of preoperative anemia and iron deficiency in adult cardiac surgery patients.
        Anesth Analg. 2022; 135: 532-544
        • Litmathe J
        • Kurt M
        • Feindt P
        • Gams E
        • et al.
        Predictors and outcome of ICU readmission after cardiac surgery.
        Thorac Cardiovasc Surg. 2009; 57: 391-394
        • Beverly A
        • Brovman EY
        • Malapero RJ
        • et al.
        Unplanned reintubation following cardiac surgery: Incidence, timing, risk factors, and outcomes.
        J Cardiothoracic Vasc Anesth. 2016; 30: 1523-1529