Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP)

doi:10.1016/j.redar.2020.11.005

Revista Española de Anestesiología y Reanimación

Volume 68, Issue 4, April 2021, Pages 183-231

https://doi.org/10.1016/j.redar.2020.11.005 Get rights and content

Resumen

La vía clínica de recuperación intensificada en cirugía cardiaca (RICC) pretende identificar, difundir y favorecer la implementación de las mejores actuaciones basadas en la evidencia científica para disminuir la variabilidad en la práctica clínica. La puesta en marcha de estas prácticas en el proceso clínico global favorecerá la obtención de mejores resultados, acortamiento de estancias hospitalarias y en la Unidad de Cuidados Críticos, lo que permitirá una reducción de costes y una mayor eficiencia. Tras realizar una revisión sistemática en cada uno de los puntos del proceso perioperatorio en cirugía cardiaca, se han redactado recomendaciones basadas en la mejor evidencia científica disponible en la actualidad con el consenso de las sociedades científicas implicadas.

Abstract

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Section snippets

Introducción

En los últimos años, la aplicación de los programas de recuperación intensificada en las áreas quirúrgicas, también denominada en inglés fast-track surgery o enhanced recovery after surgery (ERAS), han sido los protagonistas de cambios radicales en el manejo de los pacientes. Estos programas sistematizan la aplicación de un paquete de medidas y estrategias perioperatorias destinadas a aquellos pacientes que van a ser sometidos a un procedimiento quirúrgico. Su objetivo es disminuir el estrés

Objetivos

Realizar recomendaciones basadas en la evidencia científica y el consenso de las sociedades científicas involucradas para impulsar el desarrollo de programas RICC.

Intentar homogenizar los cuidados perioperatorios de los pacientes adaptados a las pautas de la vía clínica RICC.

Metodología

Se consensuaron los diferentes puntos del cuidado perioperatorio del paciente a incluir en la presente vía clínica entre todos los componentes del grupo de trabajo.

Se dividió el trabajo en grupos de 2/3 investigadores. Para cada punto se realizó una revisión sistemática de la literatura científica mediante Pubmed, Embase y Cochrane Library, apoyándose en las diferentes Guías de Práctica Clínicas publicadas.

Cada grupo de autores realizó el análisis según la metodología PRISMA⁶, y posteriormente

Población diana

Pacientes que vayan a ser intervenidos de cirugía cardiovascular, mayores de 18 años, con un adecuado nivel cognitivo para poder comprender y colaborar en el proceso.

Se excluye a las cirugías urgentes.

Valoración del riesgo anestésico-quirúrgico

La valoración de riesgo anestésico-quirúrgico en la cirugía cardiaca es importante para establecer las medidas preventivas que mejoren los resultados de morbimortalidad durante el proceso anestésico-quirúrgico. La escala ASA PS (American Society of Anesthesiologists Physical Status Classification System) de valoración de riesgo perioperatorio se establece en la visita preanestésica y se utiliza como sistema de clasificación del estado fisiológico del paciente, siendo útil para predecir el

Antiagregación simple

Todo paciente diagnosticado con cardiopatía isquémica debe iniciar tratamiento con ácido acetil salicílico (AAS), excepto si existe contraindicación⁷³. Si se indica revascularización quirúrgica, se debe introducir igualmente lo antes posible salvo que la intervención se vaya a realizar en menos de cinco días.

23. En aquellos pacientes que no tomaban antiagregación previamente, y la revascularización se va a demorar menos de cinco días, el inicio de AAS previo a la intervención puede incrementar

Catéter de arteria pulmonar (CAP)

En algunos ensayos clínicos se ha demostrado que su uso es seguro, al contrario que varios estudios observacionales180, 181, 182, pero sin que se observaran beneficios por su utilización. Sin embargo, se ha de tener en consideración que se excluía de los ensayos a los pacientes que ya llevaban el CAP o que, por ser pacientes de alto riesgo, se consideraba que requerían su uso. Algún estudio observacional de gran tamaño apunta a que aporta beneficios en los pacientes más graves¹⁸³.

El CAP es de

Analgesia multimodal

La naturaleza multifactorial y la diversidad de vías de transmisión nociceptiva que actúan en el dolor postoperatorio justifican la utilización de analgesia multimodal para su control. Dentro de un programa de recuperación intensificada de cirugía, las diversas estrategias de la analgesia multimodal no sólo persiguen mejorar el control del dolor postoperatorio y reducir el estrés quirúrgico sino también reducir la disfunción multiorgánica inducida por el dolor no controlado, reducir los efectos

Conflicto de intereses

Los autores declaran no tener ningún conflicto de intereses.

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Cited by (6)

Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation
2023, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
The ERAS Society guidelines for perioperative care in cardiac surgery do not include recommendations to use chest wall blocks like TTP, PIF, and ESP.9 However, more recently published ERACS guidelines by the French and Spanish Societies of Anesthesia and Intensive Care Medicine and the French Society of Thoracic and Cardiovascular Surgery recommended performing locoregional analgesia, favoring United States-guided blocks of the chest wall as a single or continuous injection to improve analgesic management and reduce the occurrence of postoperative complications and LOS in the ICU.31,32 This is more in line with recently published studies describing chest wall block usage as a part of multimodal intraoperative and postoperative pain control.33
Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors’ cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020.
The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors’ institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients’ time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium.
The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers’ satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients.
The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.
Anesthetic management of surgical mitral valve repair
2022, Cirugia Cardiovascular
La cirugía de la válvula mitral ha experimentado cambios muy significativos en los últimos años, desde el reemplazo valvular relativamente sencillo, hasta la reparación compleja de la válvula mitral que incluye el uso de neocuerdas. La reparación de la válvula mitral mínimamente invasiva es un componente del concepto de recuperación postoperatoria intensificada (ERAS, por sus siglas en inglés), es un avance más en el manejo de la enfermedad de la válvula mitral que se aleja del abordaje de la esternotomía media clásica y, por lo tanto, exige un enfoque diferente desde el punto de vista anestésico. Es esencial la evaluación preoperatoria con una optimización de varios sistemas, tal como se documenta minuciosamente en el consenso SEDAR, SECCE y AEP. La selección y preparación adecuada del paciente, junto con un enfoque sistemático planificado para el manejo intraoperatorio, es primordial que no haya complicaciones durante la fase intraoperatoria y una recuperación rápida en el período postoperatorio, lo que garantizará un buen resultado para el paciente.
Mitral valve surgery has undergone very significant changes over the last few years from relatively straightforward mitral valve replacement to complex mitral valve repair including insertion of neo-chordae. Minimally invasive mitral valve repair, a constituent of the cardiac enhanced recovery after surgery (ERAS) concept, is a further development in the management of mitral valve disease which involves moving away from the classical midline sternotomy and thus demands a different approach to the anesthetic management. Preanesthetic evaluation with optimising various organ systems is essential as thoroughly documented in the SEDAR, SECCE and the AEP consensus guidelines. Appropriate patient selection and preparation along with a planned systematic approach to the intraoperative management is essential for a smooth intraoperative period and rapid recovery in the postoperative period which would result in a good patient outcome.
Guidelines for extracorporeal circulation
2022, Cardiopulmonary Bypass: Advances in Extracorporeal Life Support
Numerous extracorporeal life support procedures are currently conducted worldwide for extracorporeal circulation (ECC) running. The contribution of the basis, indications, and side effects of ECC on the guidelines remains controversial despite extensive clinical and experimental research done over many years. Because of the lack of scientific evidence for some topics in this field, many recommendations are allowed to be based on consensus, necessitating an inevitable call for more scientific and new researches on many aspects of extracorporeal life support. Since the pathophysiology of the ECC-related systemic inflammatory response is multifactorial, the generation of inflammatory responses manifests mainly as subclinical organ dysfunctions, but severe multiorgan dysfunction can manifest associated with coagulopathy, respiratory failure, myocardial dysfunction, renal insufficiency, etc. Therefore guidelines for ECC should be open to new ideas, procedures, devices, and as well personal daily practices, and they should be revised bi-annually by high-experienced professionals and high-volume studies supported by real word data.
Co-Management Reduces Mortality in Post-Sternotomy Mediastinitis
2022, Surgical Infections
A retrospective clinical analysis of rescue tracheal intubation
2022, Research Square
Improved recovery protocols in cardiac surgery: A systematic review and meta-analysis of observational and quasi-experimental studies
2021, MEDICC Review

^☆: Este documento de consenso de la Sociedad Española de Anestesiologia, Reanimacion y Terapeutica del Dolor (SEDAR), la Sociedad Española de Cirugia Cardiovascular y Endovascular (SECCE) y la Asociacion Española de Perfusionistas (AEP), se publica simultaneamente en Cirugia Cardiovascular (https://doi.org/10.1016/j.circv.2020.11.004) y Revista Española de Anestesiologia y Reanimacion (https://doi.org/10.1016/j.redar.2020.11.005), con el consentimiento de los autores y editores.

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Resumen

Abstract

Section snippets

Introducción

Objetivos

Metodología

Población diana

Valoración del riesgo anestésico-quirúrgico

Antiagregación simple

Catéter de arteria pulmonar (CAP)

Analgesia multimodal

Conflicto de intereses

Ann Thorac Surg.

J Thorac Cardiovasc Surg.

Br J Anaesth.

Clin Nutr.

Am J Cardiol.

Ann Thorac Surg.

Br J Anaesth.

Nutrition

J Thorac Cardiovasc Surg.

Clin Nutr.

Surg Clin North Am.

J Am Coll Cardiol.

Can J Cardiol.

Diabetes Metab.

Ann Thorac Surg.

Ann Thorac Surg.

Am J Cardiol.

Transfus Med Rev.

Heart Lung Circ.

J Am Coll Cardiol.

Can J Cardiol.

J Am Coll Cardiol.

Can J Cardiol.

Br J Anaesth.

Anesthesiol Clin.

J Cardiothorac Vasc Anesth.

J Surg Res.

Nutrition.

Best Pract Res Clin Anaesthesiol.

J Am Coll Cardiol.

J Cardiothorac Vasc Anesth.

Cir Cardiovasc.

Rev Esp Cardiol.

Ann Thorac Surg.

J Arrhythm.

J Thromb Haemost.

J Am Coll Cardiol.

Am J Emerg Med.

Ann Thorac Surg.

Anesthesiol Clin.

Does modern cardiac surgery require conventional intensive care?

Eur J Cardiothorac Surg.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement

PLoS Med.

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

BMJ.

ASA Physical Status Classification System

American Society of Anesthesiologists Classification

StatPearls.

EuroSCORE II

Eur J Cardiothorac Surg.

Systematic review and meta-analysis on the impact of preoperative atrial fibrillation on short-and long-term outcomes after aortic valve replacement

J Cardiovasc Surg (Torino).

Systematic review on the predictive ability of frailty assessment measures in cardiac surgery

Interact Cardiovasc Thorac Surg.

Current evidence about nutrition support in cardiac surgery patients-what do we know?

Nutrients.

Visceral congestion in heart failure: right ventricular dysfunction, splanchnic hemodynamics, and the intestinal microenvironment

Curr Hear Fail Rep.