Enhanced Recovery After Surgery (ERAS) for us cardiac kids

[PsyDanny]

So there was a post going around Facebook today of a 23 year old in India that had some kind of heart surgery using only an epidural rather than general anesthesia. Had a picture of him staring up at the camera with his heart exposed. I made a "so weird" post, mostly out of concern for trauma (just generally seems stressful, and then what about the curve balls that come up. Yikes). Anyhow, after a bit, one of my fraternity brothers (a smart guy, and a really good dude) posted the following:

"Dan, it's the latest application of ERAS, enhanced recovery after surgery. This protocol is saving lives around the world, but is resisted by about 95% of surgeons in the US who have been paid to treat complications, not prevent them (this is reducing under ACA, but exceptions abound). ERAS, especially the most current versions (having your doctor affirm that they use ERAS doesn't guarantee currency), reduces complications, which improves recovery times, lowers morbidity and mortalitiy rates...and lengthens long-term life expectancy post-op. You could decide to hate it, but you could also ask Dr. Kshettry questions like 1) how much pre-op fluids he pushes (waaaay too much is traditional, minimal fluid push saves lives), 2) what steps he and his team will be taking pre-, peri-, and post-op to limit opioid use (cheap, effective at pain control, but dramatically slows recovery even if you don't become addicted) 3) what the pre-and post-op food orders are likely to be (traditional nutrition plans focus on starving a body that will soon, then has just launched, an intensive healing/recovery response -- as foolish as fasting before and after running a marathon). I can help you direct him to the President of the US ERAS society if he wants your surgical recovery to be more evidence-based than most patients in the country."

I did a search on this group, and could not find anything that suggests this topic has been discussed. So was wondering what thoughts you all might have on the topic in general (see some additional links below), as well as those regarding my friend's thoughts/recommendations.

The first link describes some of the general ERAS concepts, although mostly geared to radical cystectomy:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202008/

One geared towards cardiac surgery:

http://www.acta.org.uk/abstracts/abstract.asp?a=SIJEGOKI243478SAOCOM25062014_91

And a third about on-going clinical trials, specifying cardiac surgery with bypass:

https://clinicaltrials.gov/ct2/show/NCT02479581

Maybe some of you will recognize some of this in your own procedures / experiences, who knows?

As for me, it is all part of these weekends spent online - reading through VR.org and the Facebook Heart Valve Surgery Support Group, etc., as I count down towards my pre-op appointment on June 21, and my aortic valve replacement surgery scheduled with Dr. Vibhu Kshettry at Abbott Northwestern / Minneapolis Heart Institute of June 29.

 

[almost_hectic]

Enhanced recovery? No thanks! Not sure I even understand the logic... but how fast is fast enough when recovering from open heart surgery?! You take as long as it takes, that's fast enough in my book. Why try to rush things when it's as important as your heart? I experienced recovery more and more each week all the way up till about 6 months and that was part of rest and commitment to cardiac rehab. Trust me having a heart cath and being conscious was weird enough... Opened up for surgery, no freaking way. There's five hours they can put me under.

 

[pellicle]

wow ... and if you so much as twich at the wrong time you've just caused the surgeon to nick the wrong thing.

Full anaesthetic is not just for your comfort, its for your protection.

It never ceases to amaze me how far people are willing to go, how much long term damage, how many quacks they will submit themselves to, how much eventual pain they are willing to under go to kick the can down the road further, or to avoid confronting their own irrational fears.

 

[PsyDanny]

@ Almost Hectic the idea is that there are some things - such as pre-op nutrition (the expectation to not eat or drink after midnight before surgery) that are founded on some specious dogmas and that things like carb loading prior to surgery help the process along. It seems that the concepts promote better outcomes on a variety of levels - not so much faster recovery, but better recovery. At least that is my take.

@ Pellicle The ERAS really is not about the epidural story - while it may be a factor in some kinds of surgeries - it seems that it is about examining old dogmas that may actually inhibit good recovery.

At least that is my take when I considered the other articles.

Regarding the epidiural thing - not me either. I'd be bored to tears or shared to death.

 

[Paleowoman]

I can't imagine heart surgery under epidural. But I've had two operations under epidural (emergency caesarean/abdominal surgery and knee surgery) and they are definitely preferable to having general anaesthesia as it's far less stressful for the body and recovery is much quicker and easier. During the knee surgery, which was the first time my surgeon had had a patient request epidural (this was nearly 20 years ago), the anaesthetist sat beside my head and talked with me throughout surgery. I also know of someone who had a hip replacement with epidural and prostate surgery is now often done with epidural (my father had prostate surgery when he was 80 with epidural). You cannot feel or move any part of your body below the level of the epidural injection. In addition they put a screen between the patient's face and the site the surgeon is working on so that the patient doesn't look or get psychologically stressed by the work. But goodness, heart valve replacement that way ? I can't quite believe that since the epidural would have to be given so high up in the spine which would affect the patient from the neck down and affect all the systems below that level, and for several hours after surgery too, ie much longer than they are affected with general anaesthesia - the patient wouldn't be able to breathe unaided for a long time post surgery (unless they have short lasting epidurals these days) which would mean more time on the ventilator so this kind of heart surgery doesn't make sense. I know they put in pace makers and sometimes stents without a general, they use a local but not an epidural. The links to the ERAS seemed more about nutrition and physio, I didn't see anything about epidural in cardiac surgery.