AUDIT FOR ASSESSMENT OF THE FULFILLMENT OF CARDIAC ERAS GUIDELINES IN LOW EURO-SCORE II CARDIAC SURGICAL PATIENTS IN THE FREEMAN HOSPITAL.

Abstract

<h3>Introduction</h3> Enhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. These programs aim to reduce complications and promote an earlier return to normal activities. <h3>Aim</h3> Investigate the fulfilment of cardiac ERAS guidelines in low euro-score II cardiac surgical patients in the Freeman hospital in 2020. <h3>Patients & Methods</h3> A retrospective investigation of fulfillment of ERACS recommendations in patients with low euro-score II. - Data collected from the surgical data-base in 2020 and patients e-records. - The recommendations from the ERACS 2019 guidelines were used as a reference. Audit Results: The ERACS guidelines investigated included: - Preoperative data: - ALL patients had Pre-operative Albumin level done. - None of the patients had initiation of Preoperative multimodal analgesic. - None of the patients stopped smoking & hazardous alcohol 4 week before elective surgery. - None had preoperative CHO Loading. - Preoperative HbA1c in 69% of patients. - Clear liquids continued up to 2 to 4 hours before GA in 51% of patients. - Intraoperative data: - In ALL patients Hyperthermia was avoided while rewarming on CPB. - In ALL patients Tranexamic acid was given during on-pump. - Postoperative data: - All patients had Perioperative glycemic control. - ALL patients had an insulin infusion for hyperglycemia postoperatively. - In ALL patients a postoperative delirium screening tool used at least once per nursing shift . - In All patients persistent hypothermia after CPB was avoided. - The peri-operative, multimodal, opioid-sparing, pain management plan: Paracetamol: ALL Tramadol: None Dexmedetomidine: None Gabapentin: None Regional anaesthesia: None - ALL had thromboprophylaxis after surgery . - None had early detection of AKI. - All patients had early postoperative enteral feeding and mobilization. - 76% were extubated within 6 hrs. Audit Recommendations: - Initiate our own ERAS cardiac program. - Add engagement tools in pre-operative education. - Pre-habilitation and optimization for patients with multiple comorbidities. - Smoking and alcohol cessation. - Pre-operative HbA1C in all cases. - Preoperatrive correction of nutritional deficiency . - Clear liquids continued up to 2 to 4 hours before GA. - Oral CHO 2-4 h before surgery. - Pre-operative multimodal analgesic (Gabapentin 300 mg and Paracetamol 1000 mg given orally in preoperative holding area). - Minimal anxiolytics before surgery - Surgical site infection reduction care bundle. - Rigid sternal fixation. - Intraoperative multimodal analgesia. - Strategies to ensure early extubation within 6 h of surgery. - Avoid stripping or breaking the sterile field of chest tubes to remove clots. - Early detection of kidney stress - Goal-directed fluid therapy: - Early removal of Lines and drains - Management of pre-operative anaemia. - Goal directed perfusion strategies. - A protective lung ventilation strategy. ASSESSMENT OF THE FULFILLMENT OF CARDIAC ERAS GUIDELINES IN LOW EURO-SCORE II (<3) CARDIAC SURGICAL PATIENTS IN THE FREEMAN HOSPITAL, IN CALENDAR YEAR 2020.