Objectives There are multiple published guidelines regarding comprehensive patient blood management, centered on the three pillars of patient blood management, manage preoperative anemia, minimize blood loss, and tolerate intra/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based cardiac surgery patient blood management. Methods Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for patient blood management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. Results Preoperatively there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin, and to discontinue DAPT if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. Conclusion The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Utilizing recommendations from existing guidelines, we have created a turnkey order set to facilitate the implementation of patient blood management. There are multiple published guidelines regarding comprehensive patient blood management, centered on the three pillars of patient blood management, manage preoperative anemia, minimize blood loss, and tolerate intra/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based cardiac surgery patient blood management. Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for patient blood management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. Preoperatively there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin, and to discontinue DAPT if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Utilizing recommendations from existing guidelines, we have created a turnkey order set to facilitate the implementation of patient blood management.
BackgroundPostoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery.MethodsSubject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type.ResultsPreoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery.ConclusionsDespite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.
Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.
Abstract As patients continue to live longer from diseases that predispose them to right ventricular (RV) dysfunction or failure, many more patients will require surgery for acute or chronic health issues. Because RV dysfunction results in significant perioperative morbidity if not adequately assessed or managed, understanding appropriate assessment and treatments is important in preventing subsequent morbidity and mortality in the perioperative period. In light of the epidemiology of right heart disease, a working knowledge of right heart anatomy and physiology and an understanding of the implications of right-sided heart function for perioperative care are essential for perioperative practitioners. However, a significant knowledge gap exists concerning this topic. This manuscript is one part of a collection of papers from the PeriOperative Quality Initiative (POQI) IX Conference focusing on “Current Perspectives on the Right Heart in the Perioperative Period.” This review aims to provide perioperative clinicians with an essential understanding of right heart physiology by answering five key questions on this topic and providing an explanation of seven fundamental concepts concerning right heart physiology.
Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.
