Intraoperative oliguria results from the release of stress and antidiuretic hormones. Clearance of fluids during anaesthesia is only a small fraction of the value observed in the conscious state.
During anaesthesia permissive oliguria can be tolerated, which is not an indication for fluid administration if it is an isolated symptom. Anuria is an alarming symptom and requires quick diagnosis. A surgical insult induces hyperglycaemia and hypercoagulation. Several minutes after skin incision, the hypothalamus stimulates the release of pituitary hormones and in consequence of cortisol, which leads to gluconeogenesis, protein catabolism and loss of muscle mass. The activation of the sympathetic system generates the release of endogenous amines and intensifies hyperglycaemia. Improper control of glycaemia increases the risk of infection and incidence of cardiac events or even deaths.
More restrictive control is indicated in some selected patients provided that hypoglycaemic incidents are fully prevented [ 22 ]. Cytokines and acute phase proteins circulating in blood create hypercoagulation but also stimulate fibrinolysis. In the postoperative period, oral intake of liquids should be initiated as quickly as possible. The only contraindications are nausea and vomiting. Intravenous fluid administration after surgery shows no benefits.
To cover fluid requirements after surgery, the patient should receive 1. A relevant aspect of monitoring is fluid balance. The daily balance around zero decreases the risk of complications and shortens the hospital stay. The balance can be controlled during the first postoperative days by weighing patients. The weight and balance are strictly correlated in the first four postoperative days. Moreover, early oral feeding is essential. It should be started 24 hours after surgery.
This protocol of management reduces insulin resistance and nitrogen excretion, limits the muscle mass loss, improves wound healing, and decreases the risk of lung and surgical site infections. The use of propofol for anaesthesia reduces the incidence of PONV. Similar effects are produced by short-term fasting, preoperative administration of fluids with carbohydrates and perioperative normovolaemia.
The presence of a gastric tube increases the incidence of vomiting, atelectasis and pneumonia. There are no rational reasons for routine tube leaving after surgery. The tube should be left only in cases of prolonged postoperative ileus [ 23 ]. Paralytic ileus in the postoperative period results from the limited release of intestinal hormones, the impaired function of the central or autonomic nervous system and the release of inflammatory response transmitters.
Pain management is essential. The therapy should be adjusted to the procedure performed. Multimodal analgesia is the treatment of choice. After cardiac procedures sternotomy, thoracotomy the maximum pain intensity is observed on the first two postoperative days. Female and male patients below the age of 60 years have stronger pain sensations. Each department or unit should have the standard of pain management. It includes the 3 C rule Comfortable, Cooperative, Calm. The first step of this brilliant strategy is analgesia. Sedation should be targeted and the target is quick mobilisation.
The prerequisite of success is the promotion of proper cycles of sleep and staying awake, good atmosphere in the unit and family involvement. A dramatic postoperative complication increasing the risk of death is delirium [ 23 , 24 ]. The predisposing factors are older age, history of cognitive disturbances, generalised atherosclerosis, and anaemia. The triggering factors are acute destabilisation of the clinical condition e.
In high-risk patients, a low dose of haloperidol for prevention can be administered. Similar effects can be achieved with a low dose of atypical neuroleptics — risperidone 1 mg after , olanzapine or dexmedetomidine sedation. Quetiapine reduces the duration of delirium. The outcomes of such preventive interventions are not explicit [ 25 ]. Atrial fibrillation is a risk factor of central nervous system CNS stroke, acute kidney failure requiring renal replacement therapy, prolonged hospital stay and mortality.
Moreover, drug doses should also be individually tailored. The ERAS introduced the term of early goal-directed mobilisation [ 28 ]. Early mobilisation is a prerequisite of success of this state-of-the-art strategy. It involves physical exercises and walking already during the surgery day. Thanks to such physiotherapy, the hospital stay has been shortened and the self-reliance scores during the 6 post-hospitalisation months have improved. In patients undergoing cardiac surgical procedures, this management should be introduced during the first postoperative day.
The main idea that should be considered by all individuals involved in surgery is the individualisation of management. There is no such measure that matches all individuals. Almost every patient can be prepared, except for patients undergoing urgent and emergency surgery. However, it should be taken into account that the incidence of failures in the implementation of the entire protocol ranges between 3. The causes of failures include patient-, procedure- and management-related factors although to a lesser degree [ 12 ]. This is most commonly observed in cases of re-surgery or complex urgent procedures.
The procedure can also be additionally complicated by postoperative bleeding, tamponade, necessary surgical revision and unanticipated incidents.
Failure to observe the protocols of preoperative preparation and rules regarding the anaesthesia, weaning from a ventilator, and the protocol of sedation or pain management strategy are adverse events associated with organisation [ 28 ]. The introduction is extremely slow as the habits are difficult to change.
It requires team work. The prepared patient should be managed by the prepared team. It is necessary to use standards, protocols and checklists. The original ERAS, best analysed in colorectal surgery, contains 22 perioperative interventions. The implementation of ERAS in cardiac surgery patients should optimally be based on the Deming cycle, the scheme illustrating the basic rule of continuous improvement. The cycle consists of 4 stages — Plan-Do-Check-Act. The elements of ERAS should be chosen and verified in a pilot study, and the results should be analysed and implemented to the standard of perioperative care.
National Center for Biotechnology Information , U. Journal List Kardiochir Torakochirurgia Pol v. Kardiochir Torakochirurgia Pol. Published online Apr 4. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Address for correspondence: Prof. Ewa M.
Oxford Textbook of Cardiothoracic Anaesthesia : R. Peter Alston :
Received Dec 18; Accepted Jan Abstract The concept of early recovery after surgery ERAS consists of bundle interventions during the pre-, intra- and postoperative periods and team work. Keywords: early recovery after surgery, cardiac surgery, postoperative complications. Introduction The incidence of postoperative complications significantly affecting the quality of life is increasingly high due to the profile of patients referred for cardiac surgery.
The preoperative period The preoperative management is focused on the provision of detailed information and counselling as well as lifestyle interventions. The intraoperative period During surgery, normothermia should be maintained. The postoperative period In the postoperative period, oral intake of liquids should be initiated as quickly as possible. Disclosure The authors report no conflict of interest. References 1. Vymazal T. Fast-track is more than physiological anaesthesia. Heart Lung Vessels. Fast-track cardiac care for adult cardiac surgical patients.
Cochrane Database Syst Rev. Clin Nutr. BMJ Open. Aggregation of marginal gains in cardiac surgery: feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients. J Cardiothorac Vasc Anesthesia. Pre-admission interventions to improve outcome after elective surgery — protocol for systemic review. Syst Rev. Br J Anaesth.