Goal Directed Therapy

Created: October 10, 2023

Last Updated: November 18, 2023

Contributor(s):

ERAS Cardiac TKO Writing Group

Editor(s):

Kevin Lobdell MD

Summary

To assist clinicians in bringing existing guidelines and best practice recommendations to the bedside, ERAS Cardiac has created a series of "Turnkey Order Sets". These order sets have been created following review of the existing evidence, and provide a guide for implementation of these ERAS elements.

Turnkey Order Set (TKO) Methodology

To assist with implementation of cardiac enhanced recovery after surgery (ERAS), we have created a sample turn key order set (TKO). The order set has been translated by subject matter experts using accumulated evidence, peer-reviewed literature, and current enhanced recovery practices.

Orders derived from Class I or IIA recommendations across all referenced guidelines and consensus manuscripts appear in the TKO in bold type.

Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by evidence published in peer-reviewed journals, were also included in italicized type.


Decisions regarding order inclusion were made based on estimated benefit, risk, cost, implementation complexity, and generalizability. Each of these orders should be considered based on local institutional priorities, resources, practices, and expertise.

The Turnkey Order Set PDF in this module is intended for use by ERAS Cardiac Society Members to assist in building order sets at their own institution. They are permitted to be downloaded.

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ERAS Cardiac VTC Disclaimer:

The VTC, and all included content, is intended to inform ERAS Cardiac Members in a multitude of topics related to enhanced recovery. The information included has been provided by other enhanced recovery experts and should be used for educational purposes only. It is not intended to describe, recommend, or suggest any specific medical practice or intervention, nor should it be considered as formal medical advice or consultation. The ERAS Cardiac Society cannot guarantee that the information on the VTC is accurate or complete in every respect. Therefore, ERAS Cardiac Society is not responsible for any errors or omissions in the content, or medical results that occur with the application of the information obtained while using the VTC. All healthcare professionals should continue to use sound clinical judgment and prescribe therapies based on the best medical knowledge at their disposal.

All the material presented on the VTC is the intellectual property of the ERAS Cardiac Society, its contributors, and its sponsors. Unless explicitly stated, the information, images, audio, video, and other content may not be reproduced (in whole or in part) in any way without the written permission of the ERAS Cardiac Society.

If you have any questions or comments about the ERAS Cardiac VTC, please email: VTC@erascardiac.org

Educational Materials

GDT Turnkey Order Set

References:

1. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019 Aug 1;154(8):755-766. doi: 10.1001/jamasurg.2019.1153. PMID: 31054241.

2. Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med. 2022 Jun;41(3):101059. doi: 10.1016/j.accpm.2022.101059. Epub 2022 Apr 30. PMID: 35504126.

3. Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L; EACTS/EACTA/EBCP Committee Reviewers. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg. 2020 Feb 1;57(2):210-251. doi: 10.1093/ejcts/ezz267. PMID: 31576396.

4. Brown JR, Baker RA, Shore-Lesserson L, Fox AA, Mongero LB, Lobdell KW, LeMaire SA, De Somer FMJJ, Wyler von Ballmoos M, Barodka V, Arora RC, Firestone S, Solomon R, Parikh CR, Shann KG, Hammon J. The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery-Associated Acute Kidney Injury. Ann Thorac Surg. 2023 Jan;115(1):34-42. doi: 10.1016/j.athoracsur.2022.06.054. Epub 2022 Dec 20. PMID: 36549802.

5. Lobdell KW, Chatterjee S, Sander M. Goal-Directed Therapy for Cardiac Surgery. Crit Care Clin. 2020 Oct;36(4):653-662. doi: 10.1016/j.ccc.2020.06.004. Epub 2020 Aug 12. PMID: 32892819.

6. Recco DP, Roy N, Gregory AJ, Lobdell KW. Invasive and noninvasive cardiovascular monitoring options for cardiac surgery. JTCVS Open. 2022 Apr 11;10:256-263. doi: 10.1016/j.xjon.2022.02.028. PMID: 36004243; PMCID: PMC9390282.

7. Lobdell KW, Haden DW, Mistry KP. Cardiothoracic Critical Care. Surg Clin North Am. 2017 Aug;97(4):811-834. doi: 10.1016/j.suc.2017.03.001. PMID: 28728718.

8. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. 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 Nov;43(11):1551-1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21.

9. Lobdell K, Camp S, Stamou S, Swanson R, Reames M, Madjarov J, Stiegel R, Skipper E, Geller R, Velardo B, Mishra A, Robicsek F. Quality improvement in cardiac critical care. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1(1):16-20. PMID: 23439222; PMCID: PMC3484537.

10. Stamou SC, Camp SL, Reames MK, Skipper E, Stiegel RM, Nussbaum M, Geller R, Robicsek F, Lobdell KW. Continuous quality improvement program and major morbidity after cardiac surgery. Am J Cardiol. 2008 Sep 15;102(6):772-7. doi: 10.1016/j.amjcard.2008.04.061. Epub 2008 Jun 28. PMID: 18774005.

11. Stamou SC, Camp SL, Stiegel RM, Reames MK, Skipper E, Watts LT, Nussbaum M, Robicsek F, Lobdell KW. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008 Aug;136(2):494-499.e8. doi: 10.1016/j.jtcvs.2007.08.081. PMID: 18692663.

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