Optimizing Perioperative Care for Cardiothoracic Surgery Patients
Optimizing perioperative care for those undergoing cardiac surgery can reduce risks, conserve resources and ensure better outcomes – this is particularly true for those requiring coronary artery bypass graft (CABG) surgery.
Poor tissue perfusion and oxygenation due to hypovolemia or heart dysfunction is one of the primary contributors to post-operative complications and suboptimal outcomes, thus prompting goal-directed fluid management and effective hemodynamic monitoring to minimize risks and optimize outcomes.
Preoperative Optimization
Preoperative optimization refers to preparing patients for surgery through systematic evaluation and management of their medical conditions. Perioperative interventions aim to decrease surgical risk by targeting modifiable factors like hypertension, diabetes and smoking – yet even with recent advances in surgery the estimated rate of major adverse cardiac events (MACEs) remains high and is projected to rise due to an aging population.
Most adverse events are preventable by selecting suitable patients and employing effective management strategies. However, primary care physicians (PCPs) face practice production pressures and health care delivery circumstances which make it challenging for them to provide optimal patient assessment, risk stratification and perioperative interventions as required. As PCPs often only gain access to patients after they are referred for surgery, many comorbidities go undiagnosed prior to undergoing procedures – this neglect contributes to postoperative complications like atelectasis, pneumonia infections, extended hospital stays and morbidity.
Intraoperative Management
Hypovolemia or cardiac dysfunction resulting in inadequate tissue perfusion and oxygenation is one of the most frequent postoperative complications, but systematized fluid administration guided by functional hemodynamic monitoring can mitigate this risk and enhance outcomes.
Nurses play an essential part in providing patient-centric care, implementing aseptic techniques to maintain sterility in surgical fields, ensuring optimal surgical access and positioning, providing critical information, anticipating needs promptly, reassurance all parties involved throughout a complex procedure. In addition, compassion and effective communication is demonstrated with both patients, their family, healthcare team members, as well as any others involved in order to promote understanding and provide assurance throughout.
Preoperative risk stratification is an integral element of optimizing perioperative care, yet mortality risk scores based on conventional logistic regression analysis often exhibit limited predictive ability when applied to subpopulations such as those living with rheumatic heart disease or elderly individuals (32,33). Furthermore, advanced machine learning models have demonstrated superior predictive capacity over traditional methods when applied to these patient groups (32-33).
Postoperative Management
An integrative approach to patient screening and care planning enhances informed consent for surgery. Advancements in minimally invasive techniques, prevention of postoperative cardiac arrhythmias and bleeding, as well as prehabilitation have all proven successful at improving outcomes post-cardiothoracic surgery.
Preoperative administration of folic acid, intravenous iron preparations and erythropoietin has been demonstrated to significantly reduce blood transfusion needs among many patients. Postoperatively, careful evaluation for coagulopathies – specifically with use of antifibrinolytic agents or clotting factors – helps minimize bleeding.
Chest wall regional analgesia facilitates early extubation and breathing recovery. Fluid therapy should aim at maintaining normal body weight by replacing losses through regular monitoring of electrolytes (potassium, magnesium) and glycemic control, with cardiovascular rehabilitation and physiologic reintegration into the community as integral parts of successful recovery. Prevention of surgical site infection includes preoperative prophylaxis measures designed to limit microbial inoculums as well as modifiable patient risk factors like malnutrition and uncompensated diabetes – therefore critical care management expertise must ensure optimal outcomes for these patients.
Enhanced Recovery
Enhanced Recovery is a multimodal care pathway that has become widely recognized for improving postoperative outcomes and has been shown to reduce hospital length of stay and complications. The pathway includes pre-operative education, pre-anesthesia screenings, optimizing patients prior to surgery, minimal fasting with a carbohydrate beverage two hours before anesthesia, using combination pharmacologic and nonpharmacologic pain control regimens as prescribed and returning back to regular diet and activity the day of discharge.
Successful ERAS programs depend on collaboration from both clinicians and patients. All healthcare professionals, including surgeons, anesthesiologists and nurses must be involved in the process – including surgeons, anesthesiologists and nurses at Mass General; our dedicated ERAS coordinator assists patients and families through this patient-centric approach to surgical care. In turn, patients must actively engage with their class – active participants tend to achieve superior outcomes!
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