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Enhanced Recovery After Surgery: Guideline Update

Thursday, December 5, 2019

By

Daniel Engelman
V. Seenu Reddy
Alexander Gregory
Louis Perrault

Engelman DT, Grant M, Reddy VS, Gregory AJ, Perrault LP. Enhanced Recovery After Surgery: Guideline Update. December 2019. doi:10.25373/ctsnet.11310758.

Filmed at the 2019 EACTS Annual Meeting in Lisbon, Portugal, Daniel Engelman of Baystate Medical Center in Springfield, Massachusetts, moderates a discussion of the recently published guidelines of the Enhanced Recovery After Cardiac Surgery Society. Dr Engelman is joined by four other ERAS Cardiac Society board members, including Michael Grant of Johns Hopkins Hospital in Baltimore, Maryland, V. Seenu Reddy of TriStar Centennial Medical Center in Nashville, Tennessee, Alexander John Gregory of the Libin Cardiovascular Institute of Alberta, Canada, and Louis P. Perrault of the Montreal Heart Institute in Quebec, Canada. They discuss the new guidelines in depth, including key multidisciplinary interventions around cardiac surgery that provide best practices for the team and for patients by identifying phases of care as preoperative, intraoperative, and postoperative. These guidelines can be viewed on JAMA Surgery online as well as the ERAS Cardiac Society's website.

Disclosures
The following disclosures were made in relation to the roundtable:

Dr. Engelman has no relevant conflicts. The ERAS cardiac non-profit society received honoraria from Edwards-Lifesciences, Medela, and Biomerieux for speaker and consulting activity.
 
Dr Reddy reports personal fees from Astute Medical outside the submitted work.
 
Dr Perrault is on the scientific advisory board for ClearFlow Inc and a consultant and principal investigator for Somahlution.

The following disclosures were made in relation to the original article setting for the guidelines discussed in this roundtable:

Dr Khoynezhad consults for and receives speaking honoraria from Atricure Inc.

Dr Levy reported serving on research and steering committees for Boehringer-Ingelheim, CSL Behring, Octapharma, Instrumentation Labs, and Merck.

Dr Gerdisch is a consultant and principal investigator for and receives speaker honoraria from Zimmer Biomet and Cryolife and consults for and receives speaking honoraria from Atricure Inc.

Dr Arora has received honoraria from Mallinckrodt Pharmaceuticals and an unrestricted education grant from Pfizer Canada.

Dr R. Engelman is a consultant for Cryolife.

Dr D. Engelman reported personal fees from Astute Medical, Edwards Lifescience, and Zimmer-Biomet outside the submitted work.

Dr Arora reports grants from Pfizer Canada and honoraria from Mallickrodt Pharmaceuticals.

Dr Roselli reports personal fees from Abbott, Edwards, LivaNova, and Cryolife and grants and personal fees from Gore, Medtronic, and TerumoAortic, outside the submitted work.

Dr Boyle reports personal fees from ClearFlow Medical during the conduct of the study and is a founder of and has a patent to ClearFlow Medical pending and issued.

Comments

Submitted by Nirav Sangani on
An example of how products and companies have creeped into our cardiac surgery guidelines. The ERAS recommendations for chest tube patency do not mention about the use of suction ( most commonly -20cmH2O) applied to the drainage chambers connected to the chest tubes after shifting the patient to ICU. This is the most commonly utilised procedure used to drain the blood and prevent tamponade. It works very well and is used in almost all major cardiac centers. I would like to ask the authors, why no mention is made of such an important step to maintain chest tube patency. Instead they have stressed on Active chest tube clearance ( apparently a product) and all the references are about that product in the name of active chest tube clearance. There are two authors who are on the board of the company making the product. I feel that mention of the use of suction should be included in the chest tube patency section which is used worldwide and help to prevent cardiac tamponade. I would appreciate the views of other senior colleagues. These are guidelines used worldwide and I am disappointed to see the omission of this important step and promotion of a product in the name of active chest tube clearance in all the references cited. The current and future generations of cardiac surgeons will forget about the importance of suction applied post operatively if they follow these guidelines which has no mention of his important step and is promoting a product. I appeal to all the senior colleagues to share their views.
Submitted by Daniel Engelman on
We appreciate your comments. This was an evidence-driven consensus process. Potentials for conflicts were appropriately disclosed. Regarding chest tube management, there were at the time 4 clinical trials looking at active tube clearance published in peer-reviewed journals that were discovered in the formal Delphi process. Since the publication of this paper, there have been two more clinical trials looking at active tube clearance, one of which is randomized, further supporting the evidence considered in this recommendation. There were none, at the time, evaluating for superiority of suction vs no suction in cardiac surgery. There are of course papers looking at suction vs water seal in the pleural space after thoracic surgery, but we were not aware of such clinical trials for mediastinal drainage after cardiac surgery. Our process excluded thoracic surgical considerations and only focused on cardiac surgery. We hope there are more clinical trials looking at any of the important questions on this subject in the future (ie suction vs no suction, number and location of tube placement, types and sizes of chest tubes, when to remove tubes). These consensus processes are iterative and will be repeated in the future. As more evidence is published on the subject of chest tubes after cardiac surgery, it too can be considered as this process evolves.
Submitted by Nirav Sangani on
I appreciate your comment. But my concern is there is no mention at all of the use of suction after cardiac surgery which is the most commonly utilised method to prevent tamponade. Why is there no mention of this most commonly used procedure. There are many papers regarding mediastinal chest drain clearance for cardiac surgery in the literature. Why have they not been referenced. By completely omitting the most commonly utilised and practically cost effective method and even failing to mention it, it seems that the authors want to convey the message that active chest tube clearance is the only way of preventing tamponade and that no other method exists, inspite of it being successfully utilised in the last 50 years of cardiac surgery. Why have you mentioned about stripping of tubes and not of suction. It clearly is a case of promoting the product by omission of the other options available. ERAS consensus for chest tube drainage is taking the future surgeons in the wrong direction. Finally, I would like to ask all the authors. What do they use in their current practice.
Submitted by Nirav Sangani on
As Mentioned on this CTSnet website CTS Step-by-Step for Chest drains " The chest tube is then connected to the drainage canister using additional tubing and connectors and it is connected to a suction source, typically regulated to 20 cm of water. To prevent the chest tubes from becoming blocked and causing tamponade, they can be manipulated to prevent clots. Chest tube clearance methods are used on an as-needed basis rather than routinely. These include milking the tube by twisting or squeezing to move fluid within the tube or tapping the tube with forceps to facilitate drainage of blood down the narrow section of the tube." On one hand we are teaching about suction and on the other hand there is no mention in the guidelines.
Submitted by Nirav Sangani on
In the Disclosure above - Dr Engelman has reported no relevant conflicts Why have they not reported the disclosures of all the other authors As per the ERAS document " Dr Perrault is on the scientific advisory board for ClearFlow Inc " - the ones who are promoting "active clearance technology in the name of Pleuraflow. Why has the disclosure of Dr Perrault not mentioned above. Also Dr Boyle as per the ERAS document - "Dr Boyle reports personal fees from ClearFlow Medical during the conduct of the study and is a founder of and has a patent to ClearFlow Medical pending and issued " They have tried to promote their product in the name of Active clearance technology through the guidelines This is a dangerous precedent. In the

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