Episode 88: ERAS for Cardiac Surgery with Mike Grant

In this episode, episode 88, I welcome Dr. Mike Grant to the show to discuss Enhanced Recovery After Surgery (ERAS) protocols for cardiac surgery.

References:

https://www.ncbi.nlm.nih.gov/pubmed/?term=Enhanced+recovery+after+surgery+pathway+for+patients+undergoing+cardiac+surgery%3A+a+randomized+clinical+trial

https://www.ncbi.nlm.nih.gov/pubmed/?term=Enhanced+Recovery+for+Cardiac+Surgery+Noss

https://www.ncbi.nlm.nih.gov/pubmed/27321791

https://www.ncbi.nlm.nih.gov/pubmed/?term=27832832

12 Replies to “Episode 88: ERAS for Cardiac Surgery with Mike Grant”

  1. Great discussion and will likely be pushed for at most institutions in the future. You discussed turning down dexmed after 2 hours and 0.4 is very reasonable for extubation, what are most doing with ketamine? If you decide this patient is candidate for extubation is it being shut off 45-60 minutes before the end of the case or will it be continued into CVICU? Thank you.

    1. Hi Christopher,

      Because it’s a sub-hypnotic dose, Dr. Grant recommends running it right up to or even beyond extubation. He usually stops it right before so there is time to waste it (since it’s a controlled substance) but at that dose you could wake the patient up on it.

      Best,
      Jed

  2. THANK YOU FOR THE PODCAST! WE ARE IN THE PROCESS OF LOOKING AT BEST PRACTICE FOR CARDIAC ERAS…DID YOU EVER CONSIDER USING METHADONE? WE HAVE GUIDELINES FOR MAX DOSING FOR FENTANYL AND MIDAZOLAM BUT WANT TO DECREASE THE DOSE; HOW ARE YOU APPROACHING THE AMOUNT YOU ARE GIVING FOR BOTH ? ONE LAST QUESTION…WHILE ON CPB, HOW MUCH GAS IF PERFUSION RUNNING?

  3. Thanks for the podcast! Great information. We are in the process of gathering best practice for our our cardiac ERAS and I have a few questions: did you ever consider methadone and what are your thoughts on methadone for CV patients? How are you addressing fentanyl and midazolam dosing? How much gas is perfusion running while on CBP?

    1. Here is Dr. Grant’s reply:

      We considered methadone, but removed it due to concern for variable metabolism (particularly in older patients), drug-drug interactions (QT prolongation) and interest in limiting long term opioids.

      We only limit midazolam use (0.02-0.05 mg/kg) to lessen the potential for delirium, but do not specifically withhold fentanyl. However, with the other multimodals we average less than 100 mcg of fentanyl for a case now.

      On CPB we continue precedex, ketamine and keep isoflurane at 1%.

        1. Hi Lucas,

          Neither Dr. Grant nor I is aware of data specific to cardiac surgery. This is largely extrapolated data from the association between midazolam and delirium in other settings. Our push towards limited midazolam extended from the potential variability with respect to its metabolism profile, remarkable doses we used to administer (10mg/case) and desire to utilize ultra-short acting alternatives.

          Best,
          Jed

  4. By chance can you share any data that you have collected pre and post deployment of your institution’s cardiac eras protocol in terms of extubation time, duration of time in the ICU, overall length of stay, opioid usage etc.

    1. Dr. Grant and his colleagues have some papers under review that will include data on extubation times, length of stay, opioid use, rates of AKI, arrhythmia and delirium. The first should be out in JTCVS in the next 4-6 weeks so stay tuned!

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