Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients

Abstract

Objectives: The aim of this pilot study was to assess the feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS).

Design: A prospective, observational study.

Setting: A major urban teaching and university hospital and tertiary referral center.

Participants: 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).

Interventions: 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.

Measurements and main 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.

Keywords: cardiac surgery; enhanced recovery; perioperative quality improvement bundles; postoperative morbidity.