Improving care in the older and/or cardiac surgical patient.

Aging is a complex process that is accompanied by diminishing physiological reserves resulting in a decreased tolerance for stressors, which is considered the basis for frailty. The demographic evolution of the population in the Western world, in conjunction with the increased incidence of cardiovascular disease, has resulted in a significant increase in older persons requiring cardiac surgery. In addition, the older surgical population frequently requires a prolonged hospital length of stay (LOS) due to an increased incidence in adverse events such as postoperative delirium (POD). It is reasonable to assume that this trend will continue, leading to an escalating burden on the health system. Therefore, we must reconsider current recovery pathways. This includes the preoperative identification of "at-risk" patients, strategies aimed at reducing the incidence of adverse events and consequently hospital LOS, and thereby optimal allocation of resources. Postoperative recovery is determined by a variety of patient- and procedure-related risk factors. Several strategies targeting these risk factors have been described, frequently with limited evidence, to improve postoperative outcomes. Multiple strategies have been combined into a bundle of "enhanced recovery after cardiac surgery" (ERACS) guidelines to standardize and optimize perioperative care. Several strategies are not included in these guidelines despite being considered an easily modifiable risk factor e.g., scheduling the start of surgery (chapter 3). Furthermore, many elements implemented in local enhanced recovery programs are not listed, e.g., strategies to prevent POD (chapters 4 and 5), minimally invasive surgical techniques, intraoperative multimodal anesthesia, perioperative locoregional analgesia, and early ambulation (chapters 7, 8 and 9). Moreover, the impact of ERACS guidelines on postoperative outcomes, however, is still inconclusive (apart from the fact that these strategies have been found to be safe). The current PhD thesis had the general aim to improve postoperative recovery in older and/or cardiac surgical patients. To achieve this aim, we focused on interventions that increase the patients' readiness for surgery, support intraoperative homeostasis, and promote early return to normal activity. We evaluated the role of surgery starting times in the older population (work package 1). We also investigated the impact of procedural invasiveness on multiple postoperative outcomes (work package 2). Finally, we investigated the role of regional analgesia after minimally invasive cardiac surgery (work package 3) and the correlation between compliance with ERACS guidelines and postoperative outcomes (work package 4). In the first work package, we explored the relationship between procedural starting times and postoperative outcomes (chapter 3). In particular, we performed a secondary analysis of a pan-European multicentric study. This study, including over 3600 patients, showed no association between the starting times of anesthesia and postoperative outcomes. Nonetheless, we confirmed that increased age, urgency, duration of anesthesia, frailty, multimorbidity, ASA physical status, and in-patient status are important risk factors that should be further targeted in future research. In the second work package (chapter 5), we investigated the impact of procedural invasiveness in aortic valve replacement on the incidence of POD and quality of life. When comparing transcatheter aortic valve replacement (TAVR), a minimally invasive procedure, with surgical aortic valve replacement (SAVR), we observed a reduced incidence of POD following TAVR. Note that the statistical analysis was adjusted for important baseline risks. In contrast, compared to SAVR, we observed a low recovery in quality of life following TAVR, which is in line with other trials in high-risk TAVR patients. Our finding suggests that POD risk and QoL should be considered in the (shared) decision-making for TAVR and SAVR. In our third work package (chapters 6, 7, and 8), we investigated the effects of the erector spinae plane (ESP) block on postoperative pain following minimally invasive cardiac surgery. We showed in two double-blind, prospective randomized, placebo-controlled trials that the ESP block has no impact on opioid consumption, pain scores, or any other patient-centered outcomes after minimally invasive cardiac surgery. In the first trial (chapter 7), we enrolled patients undergoing minimally invasive mitral valve surgery. In the second trial (chapter 8), we enrolled patients scheduled for off-pump robotically assisted minimally invasive direct coronary artery bypass surgery. All patients perioperatively received multimodal analgesia, including dexmedetomidine, morphine, acetaminophen, and dexamethasone. At the end of surgery, an ESP block was placed, and patients were transferred to our dedicated post-anesthesia care unit centered ERACS program. Notably, our perioperative multimodal analgesia regimen resulted in less opioid consumption than what has been reported in other trials. We also observed lower dynamic pain scores with significantly faster extubation times in our population. These findings suggest that our institutional standard for perioperative multimodal analgesia provides adequate patient comfort and that the contribution of the ESP block in this setting appears negligible. Finally, in our fourth work package (chapter 9), we performed a retrospective audit including 356 cardiac surgical patients admitted in 2019 to our post-anesthesia care unit-centered ERACS program. We demonstrated a 64% compliance rate with the 23 institutionalized ERACS guidelines. Moreover, we identified an association between increased compliance with the ERACS program and improved postoperative outcomes, including reduced hospital LOS. In addition, we identified 5 particular interventions (i.e., correction of preoperative anemia, goal-directed fluid management, early line removal, early nutrition, and early ambulation) that were significantly correlated with improved postoperative outcomes. However, this does not imply causality. Additional prospective trials are required to establish evidence-based recommendations for these interventions. To conclude, we evaluated the role of multiple perioperative strategies in optimizing postoperative outcomes. The awareness for multiple risk factors contributing to worsened postoperative outcomes can aid in decision-making for surgery, anesthetic management, and postoperative care. The implementation of our institutional perioperative multimodal analgesic regimen, without an ESP block, was demonstrated to provide adequate postoperative analgesia. Based on the correlation between compliance with ERACS guidelines and postoperative outcomes, additional efforts should be made to increase the implementation and documentation of these strategies.

Jaar van publicatie:2023

Toegankelijkheid:Open