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Controversies in enhanced recovery after cardiac surgery

Abstract

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

Background

Enhanced Recovery After Surgery (ERAS) programs have become ubiquitous in the field of perioperative medicine and have played a key role in defining the essence of this relatively young discipline. These protocols have typically been applied to non-cardiac surgical populations (Wennström et al. 2020; Smith et al. 2019; Gupta and Senagore 2017), but more recently they have also been applied to cardiac surgery patients (Engelman et al. 2019). While consensus has emerged in some areas of perioperative management for patients undergoing heart surgery, considerable differences of opinion remain for others. This reflects a relative lack of evidence in the field and has led to differences in treatment plans for patients undergoing the same procedure, usually in different centers but sometimes even within the same institution.

The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS→-Cardiac) organizations are both committed to excellence in perioperative medicine, and in particular for patients undergoing high-risk surgery (Shannon et al. 2012). Recognizing that best practice comes from research addressing genuine evidence gaps, these two groups have developed this brief review of important topics in perioperative medicine related to cardiac surgery. The specific goal of this paper therefore is to review those areas of high importance, themselves defined as areas in which there is significant controversy about how best to manage patients. We have focused on five topics—those in which we believe there are answerable questions that address specific problems faced by cardiac surgical patients, and in which well-designed research studies will advance the field by providing specific answers. These topics are patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium. We address each topic individually, and provide a list of focused research questions (Table 1) which we believe represent high priority areas for perioperative cardiac researchers to address.

Table 1 Focused research questions

Main text

Patient blood management (PBM)

With an increased focus on providing value-based care by improving patient outcomes and decreasing costs, attention has turned to the role of patient blood management (PBM) to reduce unnecessary transfusions for patients undergoing cardiac surgery (Spahn et al. 2020). While many PBM methods have become widely adopted to reduce red blood cell transfusion in cardiac surgery, including routine use of anti-fibrinolytics (Derzon et al. 2019), restrictive transfusion thresholds (Hajjar et al. 2010; Mazer et al. 2017) and cell salvage (Carless et al. 2010), there remain some areas of controversy regarding other safe and effective PBM techniques.

A major area of debate in the perioperative management of cardiac surgery patients encompasses preoperative anemia. Although there is a growing body of evidence demonstrating that treating patients with iron deficiency or anemia prior to non-emergent cardiac surgery reduces transfusions (Weltert et al. 2015; Yoo et al. 2011; Spahn et al. 2019), we still lack consensus on how to screen patients for anemia, and who, how, and when to treat (Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic, Surgery, the European Association of Cardiothoracic, Anaesthesiology, and Boer 2018). The ideal hemoglobin target has not been determined, and it remains unknown whether treatment thresholds should differ for men and women. The World Health Organization definition of anemia is a hemoglobin concentration of less than 12 g/dL in women and 13 g/dL in men. Treatment may include iron alone (intravenous or oral) or in combination with erythropoietin stimulating agents (ESAs), but the ideal dosing and timing of treatment has yet to be determined. Due to the urgent nature of many cardiac surgeries, recent studies have focused on a short preoperative course, with anemia treated only days prior to surgery (Weltert et al. 2015; Yoo et al. 2011; Spahn et al. 2019), although a full response to treatment would be expected to take considerably longer. In addition to the higher costs in comparison to IV iron alone, use of ESAs in cardiac and vascular surgery patients remains off-label in the USA due to the Food and Drug Administration’s Black Box warning of potential increased risk of thromboembolism. The patients who would most benefit from the decreased transfusion risks without significantly increasing thromboembolism risk remain uncertain.

Other areas of controversy include transfusion triggers while on cardiopulmonary bypass, intraoperatively, before and after revascularization, and postoperatively (Ferraris et al. 2011; Murphy et al. 2015). Despite evidence supporting equivalent outcomes with restrictive versus liberal transfusion triggers (Hajjar et al. 2010), the relative risk of ischemia related to anemia for each of these timeframes remains unknown. Understandably, the decision to transfuse involves many factors, including patient age and comorbidities, baseline hemoglobin, and level of bleeding. But guidelines, both in terms of hemoglobin triggers and thresholds for patients undergoing cardiac surgery with cardiopulmonary bypass remain controversial.

Finally, although cell salvage has become a well-established non-pharmacologic technique to reduce transfusion in cardiac surgery patients, other techniques, including acute normovolemic hemodilution (Zhou et al. 2015) and autologous pump priming (Saczkowski et al. 2009; Hou et al. 2009; Vandewiele et al. 2013) are less widely employed and the literature is mixed. Although each method tends to show a reduction in total red blood cell transfusion, controversy remains regarding which patients are most likely to benefit from these techniques. Further, their use can be challenging in patients with lower circulating blood volume who may require relative euvolemia as well as an adequate hemoglobin concentration.

Goal-directed therapy (GDT)

The fundamental underlying principle of goal-directed therapy (GDT) relates to matching therapy with patient demands and avoiding the outstripping of the patient’s reserve throughout their hospital course. Clinical best practice includes quantitative risk assessment (Society of Thoracic Surgeons 2021; Nashef et al. 2002) when feasible and mitigation of modifiable risks. Controversy surrounding the merits of GDT may be pragmatically categorized by the phase(s) of care and related to process issues such as monitoring, therapeutics, personnel, safety, and cost.

As a result of monitoring capabilities and patient specific risks, the most common applicable phases of care for GDT in cardiac surgery include the operating room (OR) and intensive care unit (ICU) (O’Neal and Shaw 2016). Within the OR, one must consider both anesthetic methods—which increasingly include locoregional analgesia and less invasive monitoring—and perfusion practices. Both of these methods must be tailored to the surgical procedure and specific techniques, i.e., sternotomy, thoracotomy, CABG, OPCAB, valve replacement, and/or minimally invasive incisions.

The specific elements of GDT (Kapoor et al. 2017; Cheng et al. 2020) may be conveniently divided into “macro” and “micro”, with macro goals commonly including systemic blood pressure, cardiac index, systemic venous oxygen saturation, and urinary output (Cheng et al. 2020). Microgoals may include lactate and/or lactate to pyruvate ratio, base deficit, oxygen consumption index, hemoglobin, and biomarkers (i.e., inflammatory, cardiac, and urinary).

A considerable lack of agreement exists regarding the general procedural and individual patient goals and their interplay, as well as the complex relationship between physiology, metabolism and coagulation. Similarly, there is a lack of understanding and agreement on causation and correlation of macro- and microgoals with metrics such as death, acute kidney injury, mechanical ventilation time, stroke, hemorrhage, transfusions, length of stay, readmissions, and costs (Brown et al. 2016; Speir et al. 2009). The association of acute kidney injury (AKI) and GDT is perhaps most well established and provides a good example of this complexity. AKI risk models commonly include age, female sex, impaired ventricular function, diabetes mellitus, chronic kidney disease, systemic hypertension, anemia, emergency status, and pre-operative intra-aortic balloon pump use, but fail to include the above modifiable macro- and microgoals (Lobdell et al. 2020; Meersch et al. 2017; Rubino et al. 2015). In large part, these models have tended to be pre-operative in nature, but it is the modifiable nature of GDT which increases its importance in terms of patient management standardization.

In addition to the aforementioned patient specific issues, operational details such as clinician education and experience, patient-staffing ratios, teamwork, pathways, protocols, and order sets may significantly influence the feasibility of employing and monitoring various approaches to GDT (Lobo et al. 2013). Data collection into electronic health records, and their lack of interoperability with registries as well as analytic limitations, also constrain our development of insight into GDT and compliance with established protocols designed to mitigate risks (Smirk et al. 2018). Similar limitations impede the incorporation of new technologies such as biomarkers into operational routines and risk assessment models (Obradovic et al. 2020). Finally, the duration of follow-up and definitions of specific metrics such as mortality, readmission, acute, and chronic kidney disease present challenges to a comprehensive and accurate assessment of the value of GDT.

Acute kidney injury

Despite advances in the understanding of the cellular and molecular mechanisms of cardiac surgery-associated acute kidney injury (CSA-AKI) in the past decade (Bellomo et al. 2008), there is still uncertainty and a lack of consensus with regard to optimal prevention, early detection and management strategies. The high incidence of CSA-AKI and substantial impact on long-term patient outcomes as well as index admission mortality and hospital cost should drive our research efforts for improvement (Chen et al. 2021).

The current definition of AKI as described by the well-defined Kidney Disease: Improving Global Outcomes (KDIGO) criteria is neither sensitive nor specific for early identification of AKI. The limitations of serum creatinine and urine output have warranted the development of novel urinary biomarkers that have shown predictive value. Biomarkers allow the diagnosis of kidney injury to be made earlier, even in the absence of concurrent or subsequent kidney dysfunction (Meersch et al. 2017).

The most heavily studied biomarkers, NGAL and TIMP-2-IGFBP7, have demonstrated excellent performance in predicting CSA-AKI (Engelman et al. 2020; Meersch et al. 2014) and have the best accuracy and stability even in patients with congestive heart failure, diabetes, and chronic kidney disease (Kashani et al. 2013; Wang et al. 2017; Cruz et al. 2010). Controversies continue, however, regarding cutoff and test time as results from multiple studies have been inconsistent (Fan et al. 2019). A number of other biomarkers of cardiac function, inflammation and impaired renal function (Cystatin C, kidney injury molecule 1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), uromodulin, neutrophil/(lymphocyte × platelet) ratio, urinary albumin, creatinine kinase-MB, NT-proBNP, interleukin 18 (IL-18), and fibroblast growth factor 23) have been identified in the past decade that show potential for characterizing the pathophysiology of disease and improving risk stratification (Wu et al. 2019a; Kim et al. 2015; Vives et al. 2019). The increased cost and lack of current evidence in the improvement of clinical outcomes has limited their utilization as we await results from large multicenter trials.

Though there is still a paucity of evidence, improvement in risk-stratification may encourage post-operative monitoring with biomarkers, early initiation of therapy, application of anti-inflammatory therapy and avoidance of nephrotoxic agents in high-risk patients (Kim et al. 2015). Studies such as the PrevAKI RCT have shown that implementation of a KDIGO bundle (supportive measures) in high risk patients before, rather than after a change in kidney function as identified by biomarkers, reduced the frequency and severity of CSA-AKI but there was no impact on secondary outcomes up to 90 days (Meersch et al. 2017). Future studies are needed to recognize the impact on long-term outcomes. Unfortunately, despite the known benefits, compliance with all 6 components of the KDIGO guidelines in clinical practice appears to be very low (Kullmar et al. 2020).

A number of potential pharmacologic and non-pharmacologic strategies have been described for the prevention and treatment of CSA-AKI. Agents including levosimendan, N-acetylcysteine, atrial natriuretic peptide agonists, fenoldapam, and dopamine have all failed to consistently demonstrate any benefit and perhaps may lead to potential harm (Nadim et al. 2018). Nevertheless, there are ongoing studies with some of these medications including novel agents (ularitide, EA-230), well known anesthestic drugs (dexmedetomidine and propofol), as well as amino acid therapies. Though previous studies have shown no benefit in the prevention of CSA-AKI with levosimendan, the phase 4 “Effects of Levosimendan in Acute Kidney Injury After Cardiac Surgery Trial” (LEVOAKI) is currently underway (Cote et al. 2020). Ularitide, an atrial natriuretic peptide agonist and EA-230, developed to replicate the immunomodulatory effects of human chorionic gonadotropin also have RCTs underway (TRUST, 2018-004871-11 and NCT 03145220, respectively) (Cote et al. 2020). Studies on amino acid administration through either intravenous infusion or via protein meals have shown an increase in renal plasma flow and an increase in GFR as well as faster recovery from severe acute renal failure. Currently, a phase 3 RCT with 3500 patients undergoing cardiac surgery is underway to test the hypothesis of kidney protection by amino acid infusion (NCT03709264) (Vives et al. 2019).

Dexmedetomidine, an alpha-2 adrenoreceptor agonist, has shown a reno-protective effect in several studies (Peng et al. 2020). A meta-analysis focusing on CSA-AKI prevention concluded that dexmedetomidine might reduce the incidence of AKI compared to placebo, but time and dosage must be further evaluated (Liu et al. 2018). Another recent systematic review and meta-analysis evaluating the effects of propofol versus volatile anesthetics on mortality and major clinical events in cardiac surgery patients revealed that the incidence of AKI and RRT was similar between the two, and that volatile anesthetics offered no renal protection (Bonanni et al. 2020). These results are conflicting with a previous report that describes significant renal protection in cardiac surgery patients with the use of volatile agents versus total intravenous anesthesia (Cai et al. 2014). In another study, the use of remote ischemic-preconditioning (RIPC) was associated with a reduced incidence of AKI with volatile anesthetics instead of propofol (Deferrari et al. 2018). The timing of renal replacement therapy remains controversial. The highly anticipated Artificial Kidney Initiation in Kidney Injury-2 (AKIKI-2) (Gameiro et al. 2020) and Standard Versus Accelerated Initiation of Dialysis in Acute Kidney Injury (STARRT-AKI) trials are now shedding some light on the previously conflicting results (Wald et al. 2020). While questions regarding optimal risk stratification and management, diagnosis, prevention, and treatment of CSA-AKI are ongoing, research efforts strive to make a positive impact on the detrimental health and cost effects related to this disease.

Opioid analgesic reduction

Cardiac surgery has a longstanding relationship with the perioperative use of opioids. Dating back to the late 1960s opioid-based cardiac anesthesia (as described by Lowenstein (Lowenstein et al. 1969)) involved the use of large doses of intravenous morphine as the primary anesthetic for patients undergoing open aortic valve surgery. Although somewhat more refined, with providers opting for shorter-acting synthetic alternatives such as fentanyl and sufentanil, present-day cardiac anesthesia and analgesia still relies heavily on the administration of opioids (Silbert et al. 2006). Despite awareness of the harmful effects of perioperative opioid use, knowledge translation of the contribution of cardiac surgery to the opioid crisis to the medical community has been slow to gain momentum. Opioid-related side effects, including nausea, vomiting, constipation, and somnolence are recognized easily in low-to-moderate risk gastrointestinal, orthopedic and ambulatory surgeries, where recovery time is often directly associated with their occurrence (Dasinger et al. 2019; Tolvi et al. 2020). Similar issues are rarely prioritized—and are therefore underreported—in the context of cardiac surgery. Research has been devoted to establishing the association between certain surgical subtypes and new persistent opioid use (POU), defined as opioid use greater than 90 days after surgery in previously opioid-naïve patients (Brummett et al. 2017; Kent et al. 2019). The relationship has only recently been identified in cardiac surgery, where 6–15% of patients who undergo cardiac surgery develop POU, an association strengthened when the amount of postoperative opioid prescribed is high (Brown et al. 2020; Brescia et al. 2019; Clement et al. 2020).

Consensus guidelines have advocated for opioid reduction across numerous service lines (Gustafsson et al. 2019; Wu et al. 2019b), including a recent recommendation from the ERAS® Cardiac Society promoting the application of a “perioperative, multimodal, opioid-sparing, pain management plan” (Engelman et al. 2019). Unfortunately, there is relatively little evidence for non-opioid use in cardiac surgery and simple extrapolation of existing data in non-cardiac surgery may be inappropriate. Non-steroidal anti-inflammatory agents (NSAIDs) and COX-2 inhibitors are problematic due to an existing “black-box” warning in patients undergoing a CABG procedure and the high proportion of acute kidney injury in this population (US Food and Drug Administration 2020; Shaw 2017). A recent meta-analysis of gabapentinoids suggests the risk of somnolence may not outweigh any minor analgesic benefit (Verret et al. 2020). A landmark article investigating ketamine in cardiac surgery showed increased hallucinations without impacting opioid administration (Avidan et al. 2017). Neuraxial analgesia is rarely employed due to the use of systemic anticoagulation and studies of other forms of regional analgesia (i.e., erector spinae, paravertebral, sternal fascial plane block) have been limited (Mittnacht et al. 2019). Local anesthetic administration (intravenous or perineural) is both similarly underrepresented in the literature and complicated by a potentially increased incidence of perioperative arrhythmias. There is an emerging concept that may be thought of as “opioid sparing opioid therapy”, in which the use of a long-acting opioid such as methadone may lead to analgesic benefit in the first 30 days following cardiac surgery (Murphy et al. 2020). Finally, with rare exception, comprehensive phase-of-care-specific strategies have not been published, which provides little guidance to providers on how to construct a formal multimodal analgesic program (Williams et al. 2019; Grant et al. 2020). In the event non-opioid strategies are employed, additional systems-level issues have not been addressed. Prior examples of an opioid free analgesic program associated with an ERAS→ program in colorectal surgery failed to reduce opioids on discharge (Brandal et al. 2017), which is likely to be repeated in cardiac surgery unless meaningful analgesic prescription planning is addressed. Despite a longstanding relationship with opioids, the cardiac surgical community has lagged behind other disciplines in recognition of the issues associated with opioid use and the development of systematic strategies to uniquely address opioid-based anesthesia and analgesia in the cardiac surgical population.

Delirium

Delirium is a serious perioperative complication in which patients present with acute alterations in levels of consciousness, attention, and disordered cognition (Association AP 2013). Delirium occurs commonly following cardiac surgery patients with contemporary studies indicating a prevalence of at least 1 in 5 patients following their procedure (Jung et al. 2015; Arenson et al. 2013). The “3-strike” paradigm denotes the key determinants that can lead to an increased risk of delirium in patients undergoing cardiac surgery: (1) a baseline vulnerability of the brain in the older adult cardiac patient that results in a lower bio-psycho-social reserve; (2) suffering an acute cardiac stressor (i.e., new event such as cardiac surgery); and (3) further compounding post-event stressors related to processes of care in the ICU and ward phases of care (Arora et al. 2017). Importantly, the occurrence of postoperative delirium in the cardiac surgery patient has been shown to be associated with multiple short- and long-term adverse outcomes, including increased mortality, loss of functional independence and greater prevalence of long-term cognitive decline. Further work must include a greater awareness for the cardiac surgeon and perioperative specialist of the impact of delirium on the post-procedure cardiac patient. There are three key considerations for the perioperative team’s management of this vexing complication (Sanjanwala et al. 2020; Dubiel et al. 2020), and these are discussed in the following paragraphs.

The cardiac perioperative team frequently has an opportunity to obtain information about patients before their procedure. As such, an important step in the prevention of delirium is the identification of baseline risk. This should include an assessment of frailty and cognition (such as the Montreal Cognitive Assessment (Nasreddine et al. 2005) or Mini-Cog (Borson et al. 2000)) as well as anxiety, depression, and pre-procedure pain (Kosar et al. 2014). This information serves to alert the team of increased risk of postoperative delirium and to identify possible targets to optimize prior to their procedure (for example prehabilitation (Arora et al. 2018)). In addition, identification of increased risk of delirium should be included in the communication of information during clinical handoffs to ensure the perioperative team remains vigilant throughout the patient journey (Chatterjee et al. 2019).

In the postoperative phase, the variable manifestations of delirium symptom presentation, in conjunction with its fluctuating course, pose challenges for the bedside practitioner to diagnose in clinical practice (Neufeld et al. 2013). Consequently, delirium is often under-recognized, with rates of missed diagnosis reported in greater than two-thirds of cases (Neto et al. 2012). Therefore, the use of a dedicated screening tool, appropriate to the clinical environment, is essential to detect delirium when it occurs at the earliest time point in order to permit the perioperative team to determine the potential etiology (Devlin et al. 2018). While there is no universally accepted delirium screening tool for the ICU, the confusion assessment method for the intensive care unit (CAM-ICU (Ely et al. 2001)) or the intensive care delirium screening checklist (ICDSC (Bergeron et al. 2001)) are the most commonly referenced tools. Bedside screening for delirium should occur regularly, ideally once per nurse shift (Engelman et al. 2019). For the ward, it would be reasonable for the perioperative team to consider incorporating tools that are more brief (and therefore clinically feasible) such as the 3-min version of the confusion assessment method (3D-CAM (Marcantonio et al. 2014)) or the “4 A’s Test” (4AT (Tieges et al. 2020)); however, both require additional validation in the cardiac surgery patient.

Owing to the complexity of delirium pathogenesis, a single intervention will unlikely be effective once delirium occurs (Maldonado 2013). The primary approach for delirium management in the cardiac surgery patient, following the use of routine delirium risk identification and screening, is reducing risk through patient optimization and mitigation of iatrogenic pathology. In the preoperative setting, two key geriatric syndromes that impact postoperative outcomes, including delirium, are frailty and malnutrition. Previous investigations have identified that approximately 50% of older adults undergoing cardiac surgery can be considered frail (Jung et al. 2015; Lytwyn et al. 2017) as defined by a cumulative decline in multiple physiological systems resulting in a vulnerability to stressor events (Rockwood and Mitnitski 2007; Fried et al. 2001). This results in a population who are at a higher risk for poor outcomes, including delirium. This is further compounded by malnutrition, which is an unintentional nutritional imbalance, but not necessarily only decreased intake. It is present in 20% of patients presenting for cardiac surgery (Patel et al. 2014). Both of these syndromes, in addition to mental health issues, may be amenable to pre-operative optimization (i.e., prehabilitation) (Arora et al. 2018). Further studies are needed to determine the effectiveness of these interventions in preventing delirium vulnerability in older adult patients undergoing cardiac surgery.

It is increasingly recognized that the perioperative team itself can contribute to iatrogenic delirium risk (Vasilevskis et al. 2010; Vasunilashorn et al. 2018). In the postoperative phase of care, therefore, it is important to utilize an interdisciplinary approach to managing postoperative delirium. The principles of this approach are contained with the most current Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) recommendations (Devlin et al. 2018). Specific to the preventative management of delirium, routine delirium screening, early mobilization and sleep promotion are the mainstays of this clinical pathway (Arora et al. 2017). In addition, the surgical and perioperative team should include consideration of less invasive procedures and development of strategies for minimizing opioid use for postoperative pain management (Engelman et al. 2019; Arora et al. 2017).

Contemporary societal recommendations have advocated against the routine use of benzodiazepines and antipsychotic agents in favor of non-pharmacologic strategies as the first-line components of management (Engelman et al. 2019; Arora et al. 2003). Furthermore, there is no evidence that prophylactic (Page et al. 2013) or routine (Girard et al. 2018) antipsychotic use reduces delirium and these should therefore be reserved for those patients with significantly distressing symptoms or those who pose a safety concern to themselves or others (Devlin et al. 2018). More research is needed surrounding potential pharmacologic treatments. First-line non-pharmacologic strategies are consistent with the preventative measures described earlier.

An aging population will continue to contribute to a greater prevalence of heart disease in an older and increasingly frail cardiac patient population, who are themselves vulnerable to delirium. The perioperative team should view the occurrence of postoperative delirium as a quality indicator for health care delivery because it is common, associated with iatrogenesis and integrally linked to processes of care (Fatehi Hassanabad et al. 2021). The contemporary cardiac team should seek to incorporate routine risk identification during the preoperative evaluation and consider opportunities to optimize vulnerable patients while they await surgery (Enomoto et al. 2021). Modifications of intraoperative and postoperative processes of care to mitigate risk of postoperative delirium need to be undertaken and contextualized to the providing center’s clinical environment (Peng et al. 2020; Siripoonyothai and Sindhvananda 2021). Lastly, we strongly encourage the development and facilitation of team-based, multicomponent strategies to mitigate the occurrence of delirium in the postoperative cardiac surgery patient.

Conclusions

It is readily apparent that there is much work to be done if we are to improve value (better patient reported outcomes and decreased costs) in perioperative cardiac medicine. There are implications for resource utilization as well as clinical outcome improvements in the five clinical topics and research questions (see Additional file 1) we have outlined in this review. We hope that this represents the first step in identifying a research agenda that will increase consensus and reduce controversy by providing answers to well-articulated important clinical questions.

Availability of data and materials

Not applicable

Abbreviations

3D-CAM:

3-minute version of the confusion assessment method

4AT:

4 A’s test

AKI:

Acute kidney injury

CABG:

Coronary artery bypass grafting

CAM-ICU:

Confusion assessment method for the intensive care unit

CSA-AKI:

Cardiac surgery-associated acute kidney injury

ERAS:

Enhanced recovery after surgery

ERAS-CS:

Enhanced recovery after surgery–cardiac surgery

ESAs:

Erythropoietin stimulating agents

GDT:

Goal-directed therapy

ICDSC:

Intensive care delirium screening checklist

IGFBP7:

Insulin-like growth factor-binding protein 7

KDIGO:

Kidney Disease: Improving Global Outcomes

KIM-1:

Kidney injury molecule-1

L-FABP:

Liver-type fatty acid-binding protein

NGAL:

Neutrophil gelatinase-associated lipocalin

OPCAB:

Off-pump coronary artery bypass grafting

PBM:

Patient blood management

POQI:

Perioperative quality initiative

POU:

Persistent opioid use

RIPC:

Remote ischemic preconditioning

TIMP-2:

Tissue inhibitor of metalloproteinases 2

References

  • Arenson BG, MacDonald LA, Grocott HP, Hiebert BM, Arora RC. Effect of intensive care unit environment on in-hospital delirium after cardiac surgery. J Thorac Cardiovasc Surg. 2013;146(1):172–8.

    PubMed  Article  Google Scholar 

  • Arora RC, Brown CH 4th, Sanjanwala RM, McKelvie R. “NEW” prehabilitation: a 3-way approach to improve postoperative survival and health-related quality of life in cardiac surgery patients. Can J Cardiol. 2018;34(7):839–49.

    PubMed  Article  Google Scholar 

  • Arora RC, Cardinal R, Smith FM, Ardell JL, Dell’Italia LJ, Armour JA. Intrinsic cardiac nervous system in tachycardia induced heart failure. Am J Phys Regul Integr Comp Phys. 2003;285(5):R1212–23.

    CAS  Google Scholar 

  • Arora RC, Djaiani G, Rudolph JL. Detection, prevention, and management of delirium in the critically ill cardiac patient and patients who undergo cardiac procedures. Can J Cardiol. 2017;33(1):80–7.

    PubMed  Article  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. 5th ed. https://doi.org/10.1176/appi.books.9780890425596.

  • Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet. 2017;390(10091):267–75.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  • Bellomo R, Auriemma S, Fabbri A, et al. The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int J Artif Organs. 2008;31(2):166–78.

    CAS  PubMed  Article  Google Scholar 

  • Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27(5):859–64.

    CAS  PubMed  Article  Google Scholar 

  • Bonanni A, Signori A, Alicino C, et al. Volatile anesthetics versus propofol for cardiac surgery with cardiopulmonary bypass: meta-analysis of randomized trials. Anesthesiology. 2020;132(6):1429–46.

    PubMed  Article  Google Scholar 

  • Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021–7.

    CAS  PubMed  Article  Google Scholar 

  • Brandal D, Keller MS, Lee C, et al. Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study. Anesth Analg. 2017;125(5):1784–92.

    PubMed  PubMed Central  Article  Google Scholar 

  • Brescia AA, Waljee JF, Hu HM, et al. Impact of prescribing on new persistent opioid use after cardiothoracic surgery. Ann Thorac Surg. 2019;108(4):1107–13.

    PubMed  PubMed Central  Article  Google Scholar 

  • Brown CR, Chen Z, Khurshan F, Groeneveld PW, Desai ND. Development of persistent opioid use after cardiac surgery. JAMA Cardiol. 2020;5:889 Available from: https://www.ncbi.nlm.nih.gov/pubmed/32584934.

    PubMed  PubMed Central  Article  Google Scholar 

  • Brown JR, Hisey WM, Marshall EJ, et al. Acute kidney injury severity and long-term readmission and mortality after cardiac surgery. Ann Thorac Surg. 2016;102(5):1482–9.

    PubMed  PubMed Central  Article  Google Scholar 

  • Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.

    PubMed  PubMed Central  Article  Google Scholar 

  • Cai J, Xu R, Yu X, Fang Y, Ding X. Volatile anesthetics in preventing acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2014;148(6):3127–36.

    CAS  PubMed  Article  Google Scholar 

  • Carless PA, Henry DA, Moxey AJ, O'Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2010;2010(4):CD001888. https://doi.org/10.1002/14651858.CD001888.pub4.

  • Chatterjee S, Shake JG, Arora RC, et al. Handoffs from the operating room to the intensive care unit after cardiothoracic surgery: from the society of thoracic surgeons workforce on critical care. Ann Thorac Surg. 2019;107(2):619–30.

    PubMed  Article  Google Scholar 

  • Chen J-J, Chang C-H, Wu VC-C, et al. Long-term outcomes of acute kidney injury after different types of cardiac surgeries: a population-based study. J Am Heart Assoc. 2021;10(9):e019718.

    PubMed  PubMed Central  Article  Google Scholar 

  • Cheng X-Q, Zhang J-Y, Wu H, et al. Outcomes of individualized goal-directed therapy based on cerebral oxygen balance in high-risk patients undergoing cardiac surgery: a randomized controlled trial. J Clin Anesth. 2020;67:110032.

    PubMed  Article  Google Scholar 

  • Clement KC, Canner JK, Lawton JS, Whitman GJR, Grant MC, Sussman MS. Predictors of new persistent opioid use after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2020;160(4):954–63 e4.

    PubMed  Article  CAS  Google Scholar 

  • Cote JM, Murray PT, Rosner MH. New drugs for acute kidney injury. Curr Opin Crit Care. 2020;26(6):525–35.

    PubMed  Article  Google Scholar 

  • Cruz DN, Ronco C, Katz N. Neutrophil gelatinase-associated lipocalin: a promising biomarker for detecting cardiac surgery-associated acute kidney injury. J Thorac Cardiovasc Surg. 2010;139(5):1101–6.

    CAS  PubMed  Article  Google Scholar 

  • Dasinger EA, Branch-Elliman W, Pizer SD, et al. Association between postoperative opioid use and outpatient surgical adverse events. Am J Surg. 2019;217(4):605–12.

    PubMed  PubMed Central  Article  Google Scholar 

  • Deferrari G, Bonanni A, Bruschi M, Alicino C, Signori A. Remote ischaemic preconditioning for renal and cardiac protection in adult patients undergoing cardiac surgery with cardiopulmonary bypass: systematic review and meta-analysis of randomized controlled trials. Nephrol Dial Transplant. 2018;33(5):813–24.

    PubMed  Article  Google Scholar 

  • Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Reducing red blood cell transfusion in orthopedic and cardiac surgeries with Antifibrinolytics: a laboratory medicine best practice systematic review and meta-analysis. Clin Biochem. 2019;71:1–13.

    CAS  PubMed  Article  Google Scholar 

  • Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825–73.

    PubMed  Article  Google Scholar 

  • Dubiel C, Hiebert BM, Stammers AN, et al. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg. 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32859411.

  • Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001;29(7):1370–9.

    CAS  PubMed  Article  Google Scholar 

  • Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA Surgery. 2019;154(8):755–66.

    PubMed  Article  Google Scholar 

  • Engelman DT, Crisafi C, Germain M, et al. Using urinary biomarkers to reduce acute kidney injury following cardiac surgery. J Thorac Cardiovasc Surg. 2020;160(5):1235–46 e2.

    PubMed  Article  CAS  Google Scholar 

  • Enomoto K, Kosaka S, Kimura T, et al. Prevention of postoperative delirium after cardiovascular surgery: a team-based approach. J Thorac Cardiovasc Surg. 2021. Available from: https://doi.org/10.1016/j.jtcvs.2021.07.027.

  • Fan W, Ankawi G, Zhang J, et al. Current understanding and future directions in the application of TIMP-2 and IGFBP7 in AKI clinical practice. Clin Chem Lab Med. 2019;57(5):567–76.

    CAS  PubMed  Article  Google Scholar 

  • Fatehi Hassanabad A, Bahrami N, Novick RJ, Ali IS. Delirium and depression in cardiac surgery: a comprehensive review of risk factors, pathophysiology, and management. J Card Surg. 2021;36(8):2876–89.

    PubMed  Article  Google Scholar 

  • Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944–82.

    PubMed  Article  Google Scholar 

  • Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    CAS  PubMed  Article  Google Scholar 

  • Gameiro J, Fonseca JA, Outerelo C, Lopes JA. Acute kidney injury: from diagnosis to prevention and treatment strategies. J Clin Med Res. 2020;9(6):1704 Available from: https://www.ncbi.nlm.nih.gov/pubmed/32498340.

    CAS  Google Scholar 

  • Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med. 2018;379(26):2506–16.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  • Grant MC, Isada T, Ruzankin P, et al. Opioid-sparing cardiac anesthesia: secondary analysis of an enhanced recovery program for cardiac surgery. Anesth Analg. 2020;131(6):1852–61.

    CAS  PubMed  Article  Google Scholar 

  • Gupta R, Senagore A. Immunonutrition within enhanced recovery after surgery (ERAS): an unresolved matter. Perioper Med (Lond). 2017;6:24.

    Article  Google Scholar 

  • Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS((R))) Society Recommendations: 2018. World J Surg. 2019;43(3):659–95.

    CAS  PubMed  Article  Google Scholar 

  • Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010;304(14):1559–67.

    CAS  PubMed  Article  Google Scholar 

  • Hou X, Yang F, Liu R, et al. Retrograde autologous priming of the cardiopulmonary bypass circuit reduces blood transfusion in small adults: a prospective, randomized trial. Eur J Anaesthesiol. 2009;26(12):1061–6.

    PubMed  Article  Google Scholar 

  • Jung P, Pereira MA, Hiebert B, et al. The impact of frailty on postoperative delirium in cardiac surgery patients. J Thorac Cardiovasc Surg. 2015;149(3):869–75 e1–2.

    PubMed  Article  Google Scholar 

  • Kapoor PM, Magoon R, Rawat RS, et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth. 2017;20(1):83–9.

    PubMed  PubMed Central  Article  Google Scholar 

  • Kashani K, Al-Khafaji A, Ardiles T, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013;17(1):R25.

    PubMed  PubMed Central  Article  Google Scholar 

  • Kent ML, Hurley RW, Oderda GM, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg. 2019;129(2):543–52.

    PubMed  PubMed Central  Article  Google Scholar 

  • Kim WH, Park JY, Ok SH, Shin IW, Sohn JT. Association between the neutrophil/lymphocyte ratio and acute kidney injury after cardiovascular surgery: a retrospective observational study. Medicine. 2015;94(43):e1867.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  • Kosar CM, Tabloski PA, Travison TG, et al. Effect of preoperative pain and depressive symptoms on the development of postoperative delirium. Lancet Psychiatry. 2014;1(6):431–6.

    PubMed  PubMed Central  Article  Google Scholar 

  • Kullmar M, Weiss R, Ostermann M, et al. A multinational observational study exploring adherence with the kidney disease: improving global outcomes recommendations for prevention of acute kidney injury after cardiac surgery. Anesth Analg. 2020;130(4):910–6.

    PubMed  Article  Google Scholar 

  • Liu Y, Sheng B, Wang S, Lu F, Zhen J, Chen W. Dexmedetomidine prevents acute kidney injury after adult cardiac surgery: a meta-analysis of randomized controlled trials. BMC Anesthesiol. 2018;18(1):7.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  • Lobdell KW, Chatterjee S, Sander M. Goal-directed therapy for cardiac surgery. Crit Care Clin. 2020;36(4):653–62.

    PubMed  Article  Google Scholar 

  • Lobo SM, Mendes CL, Rezende E, Dias FS. Optimizing perioperative hemodynamics: what is new? Curr Opin Crit Care. 2013;19(4):346–52.

    PubMed  Article  Google Scholar 

  • Lowenstein E, Hallowell P, Levine FH, Daggett WM, Austen WG, Laver MB. Cardiovascular response to large doses of intravenous morphine in man. N Engl J Med. 1969;281(25):1389–93.

    CAS  PubMed  Article  Google Scholar 

  • Lytwyn J, Stammers AN, Kehler DS, et al. The impact of frailty on functional survival in patients 1 year after cardiac surgery. J Thorac Cardiovasc Surg. 2017;154(6):1990–9.

    PubMed  Article  Google Scholar 

  • Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry. 2013;21(12):1190–222.

    PubMed  Article  Google Scholar 

  • Marcantonio ER, Ngo LH, O’Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med. 2014;161(8):554–61.

    PubMed  PubMed Central  Article  Google Scholar 

  • Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017;377(22):2133–44.

    PubMed  Article  Google Scholar 

  • Meersch M, Schmidt C, Hoffmeier A, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;119(793–799):1551–61.

    Article  CAS  Google Scholar 

  • Meersch M, Schmidt C, Van Aken H, et al. Validation of cell-cycle arrest biomarkers for acute kidney injury after pediatric cardiac surgery. PLoS One. 2014;9(10):e110865.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  • Mittnacht AJC, Shariat A, Weiner MM, et al. Regional techniques for cardiac and cardiac-related procedures. J Cardiothorac Vasc Anesth. 2019;33(2):532–46.

    PubMed  Article  Google Scholar 

  • Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med. 2015;372(11):997–1008.

    CAS  PubMed  Article  Google Scholar 

  • Murphy GS, Avram MJ, Greenberg SB, et al. Postoperative pain and analgesic requirements in the first year after intraoperative methadone for complex spine and cardiac surgery. Anesthesiology. 2020;132(2):330–42 Available from: https://doi.org/10.1097/aln.0000000000003025.

    CAS  PubMed  Article  Google Scholar 

  • Nadim MK, Forni LG, Bihorac A, et al. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc. 2018;7(11):e008834 Available from: https://www.ncbi.nlm.nih.gov/pubmed/29858368.

    PubMed  PubMed Central  Article  Google Scholar 

  • Nashef SA, Roques F, Hammill BG, et al. Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery. Eur J Cardiothorac Surg. 2002;22(1):101–5.

    PubMed  Article  Google Scholar 

  • Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.

    PubMed  Article  Google Scholar 

  • Neto AS, Nassar AP Jr, Cardoso SO, et al. Delirium screening in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2012;40(6):1946–51.

    PubMed  Article  Google Scholar 

  • Neufeld KJ, Leoutsakos JS, Sieber FE, et al. Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly. Br J Anaesth. 2013;111(4):612–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  • O’Neal JB, Shaw AD. Goal-directed therapy in the operating room: is there any benefit? Curr Opin Anaesthesiol. 2016;29(1):80–4.

    PubMed  PubMed Central  Article  Google Scholar 

  • Obradovic M, Kurz A, Kabon B, et al. The effect of intraoperative goal-directed crystalloid versus colloid administration on perioperative inflammatory markers - a substudy of a randomized controlled trial. BMC Anesthesiol. 2020;20(1):210.

    PubMed  PubMed Central  Article  Google Scholar 

  • Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2013;1(7):515–23.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  • Patel J, Baldwin J, Bunting P, Laha S. The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia. 2014;69(6):540–9.

    CAS  PubMed  Article  Google Scholar 

  • Peng K, Li D, Applegate RL 2nd, Lubarsky DA, Ji F-H. Liu h. effect of dexmedetomidine on cardiac surgery-associated acute kidney injury: a meta-analysis with trial sequential analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2020;34(3):603–13.

    CAS  PubMed  Article  Google Scholar 

  • Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722–7.

    PubMed  Article  Google Scholar 

  • Rubino AS, Torrisi S, Milazzo I, et al. Designing a new scoring system (QualyP Score) correlating the management of cardiopulmonary bypass to postoperative outcomes. Perfusion. 2015;30(6):448–56.

    CAS  PubMed  Article  Google Scholar 

  • Saczkowski R, Bernier PL, Tchervenkov CI, Arellano R. Retrograde autologous priming and allogeneic blood transfusions: a meta-analysis. Interact Cardiovasc Thorac Surg. 2009;8(3):373–6.

    PubMed  Article  Google Scholar 

  • Sanjanwala R, Stoppe C, Khoynezhad A, Hill A, Engelman DT, Arora RC. Delirium prevention in postcardiac surgical critical care. Crit Care Clin. 2020;36(4):675–90.

    PubMed  Article  Google Scholar 

  • Shannon FL, Fazzalari FL, Theurer PF, et al. A method to evaluate cardiac surgery mortality: phase of care mortality analysis. Ann Thorac Surg. 2012;93(1):36–43 discussion 43.

    PubMed  Article  Google Scholar 

  • Shaw AD. Cardiac surgery-associated acute kidney injury: tools for enriching clinical trial populations. Can J Anaesth. 2017;64(8):793–6.

    PubMed  Article  Google Scholar 

  • Silbert BS, Scott DA, Evered LA, et al. A comparison of the effect of high- and low-dose fentanyl on the incidence of postoperative cognitive dysfunction after coronary artery bypass surgery in the elderly. Anesthesiology. 2006;104(6):1137–45.

    CAS  PubMed  Article  Google Scholar 

  • Siripoonyothai S, Sindhvananda W. Comparison of postoperative delirium within 24 hours between ketamine and propofol infusion during cardiopulmonary bypass machine: a randomized controlled trial. Ann Card Anaesth. 2021;24(3):294–301.

    PubMed  PubMed Central  Google Scholar 

  • Smirk AJ, Nicholson JJ, Console YL, et al. The enhanced recovery after surgery (ERAS) Greenie Board: a Navy-inspired quality improvement tool. Anaesthesia. 2018;73(6):692–702.

    CAS  PubMed  Article  Google Scholar 

  • Smith J, Probst S, Calandra C, et al. Enhanced recovery after surgery (ERAS) program for lumbar spine fusion. Perioper Med (Lond). 2019;8:4.

    Article  Google Scholar 

  • Society of Thoracic Surgeons. STS Risk Calculator. 2021. Available from: http://riskcalc.sts.org/stswebriskcalc/calculate. [cited 2021].

    Google Scholar 

  • Spahn DR, Muñoz M, Klein AA, Levy JH, Zacharowski K. Patient Blood Management: Effectiveness and Future Potential. Anesthesiology. 2020;133(1):212–22.

    PubMed  Article  Google Scholar 

  • Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet. 2019;393(10187):2201–12.

    PubMed  Article  Google Scholar 

  • Speir AM, Kasirajan V, Barnett SD, Fonner E Jr. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia. Ann Thorac Surg. 2009;88(1):40–5 discussion 45–6.

    PubMed  Article  Google Scholar 

  • Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic, Surgery, the European Association of Cardiothoracic, Anaesthesiology, Boer C, et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32(1):88–120.

    Article  CAS  Google Scholar 

  • Tieges Z, Maclullich AMJ, Anand A, et al. Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis. Age Ageing. 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33196813.

  • Tolvi M, Tuominen-Salo H, Paavola M, Mattila K, Aaltonen LM, Lehtonen L. Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery: a retrospective observational cohort study. Patient Saf Surg. 2020;14:27.

    PubMed  PubMed Central  Article  Google Scholar 

  • US Food and Drug Administration. Medication guide for nonsteroidal anti-inflammatory drugs (NSAIDs). 2020. Available from: https://www.fda.gov/media/72932/download#:~:text=Do%20not%20take%20NSAIDs%20right,after%20a%20recent%20heart%20attack.

  • Vandewiele K, Bove T, De Somer FM, et al. The effect of retrograde autologous priming volume on haemodilution and transfusion requirements during cardiac surgery. Interact Cardiovasc Thorac Surg. 2013;16(6):778–83.

    PubMed  PubMed Central  Article  Google Scholar 

  • Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness--crossing the quality chasm. Chest. 2010;138(5):1224–33.

    PubMed  PubMed Central  Article  Google Scholar 

  • Vasunilashorn SM, Fong TG, Albuquerque A, et al. Delirium severity post-surgery and its relationship with long-term cognitive decline in a cohort of patients without dementia. J Alzheimers Dis. 2018;61(1):347–58.

    PubMed  PubMed Central  Article  Google Scholar 

  • Verret M, Lauzier F, Zarychanski R, et al. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Anesthesiology. 2020;133(2):265–79.

    PubMed  Article  Google Scholar 

  • Vives M, Hernandez A, Parramon F, et al. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renov Dis. 2019;12:153–66.

    CAS  Article  Google Scholar 

  • Wald R, Bagshaw SM, Investigators S-A. Timing of initiation of renal-replacement therapy in acute kidney injury. Reply. N Engl J Med. 2020;383(18):1797–8.

    PubMed  Google Scholar 

  • Wang WG, Sun WX, Gao BS, Lian X, Zhou HL. Cell cycle arrest as a therapeutic target of acute kidney injury. Curr Protein Pept Sci. 2017;18(12):1224–31.

    CAS  PubMed  Article  Google Scholar 

  • Weltert L, Rondinelli B, Bello R, et al. A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single-blind randomized controlled trial. Transfusion. 2015;55(7):1644–54.

    CAS  PubMed  Article  Google Scholar 

  • Wennström B, Johansson A, Kalabic S, E-Son Loft A-L, Skullman S, Bergh I. Patient experience of health and care when undergoing colorectal surgery within the ERAS program. Perioper Med (Lond). 2020;9:15.

    Article  Google Scholar 

  • Williams JB, McConnell G, Allender JE, et al. One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program. J Thorac Cardiovasc Surg. 2019;157(5):1881–8.

    PubMed  Article  Google Scholar 

  • Wu B, Chen J, Yang Y. Biomarkers of acute kidney injury after cardiac surgery: a narrative review. Biomed Res Int. 2019a;2019:7298635.

    PubMed  PubMed Central  Google Scholar 

  • Wu CL, King AB, Geiger TM, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naive Patients. Anesth Analg. 2019b;129(2):567–77.

    PubMed  PubMed Central  Article  Google Scholar 

  • Yoo YC, Shim JK, Kim JC, Jo YY, Lee JH, Kwak YL. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology. 2011;115(5):929–37.

    CAS  PubMed  Article  Google Scholar 

  • Zhou X, Zhang C, Wang Y, Yu L, Yan M. Preoperative acute normovolemic hemodilution for minimizing allogeneic blood transfusion: a meta-analysis. Anesth Analg. 2015;121(6):1443–55.

    PubMed  Article  Google Scholar 

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AS coordinated the project, wrote the background and conclusions, contributed to the first draft, and edited the final manuscript. NG wrote the blood management section and edited the final manuscript. JB wrote the AKI section and edited the final manuscript. KL wrote the goal-directed therapy section and edited the final manuscript. MG and TG wrote the opioid reduction section and edited the final manuscript. RA wrote the delirium section and edited the final manuscript. DE wrote the abstract, contributed to the first draft, and edited the final manuscript. All authors read and approved the final manuscript.

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Shaw, A.D., Guinn, N.R., Brown, J.K. et al. Controversies in enhanced recovery after cardiac surgery. Perioper Med 11, 19 (2022). https://doi.org/10.1186/s13741-022-00250-7

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Keywords

  • Enhanced recovery after surgery
  • Patient blood management
  • Acute kidney injury
  • Opioid analgesia reduction
  • Delirium