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| The Monthly Pulse |
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| The impact of a postoperative multimodal analgesia pathway on opioid use and outcomes after cardiothoracic surgery
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| The Story |
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| While multimodal analgesia (MMA) is recommended for postoperative pain by the Enhanced Recovery After Cardiac Surgery (ERACS) Society, we have yet to see evidence-based guidelines for its use. Recently, a study was published in the Journal of Cardiothoracic Surgery which aimed to identify the impact of a standardized postoperative MMA pathway as a means of reducing opioid consumption and postoperative complications following cardiothoracic surgery. |
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| What You Should Know |
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| The study included data from 762 adults broken out into two groups: one received a newly implemented MMA pathway, while the other received the existing opioid-based pathway. Contrary to the study’s hypothesis, the use of the MMA pathway didn’t reduce opioid consumption, though patients in the MMA pathway did have earlier mobility. Nonetheless, the study’s authors believe that the development of a standardized perioperative MMA approach is still warranted.
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| Comparison of Evaluations for Heart Transplant Before Durable Left Ventricular Assist Device and Subsequent Receipt of Transplant at Transplant vs Nontransplant Centers
Target Group(s): Providers/Non-Recruiters
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| The Story |
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| According to a cohort study of more than 22,000 left ventricular assist device (LVAD) recipients from the Society of Thoracic Surgeons Intermacs Database, patients who received durable LVAD in centers that also perform heart transplants were much more likely to receive an LVAD as a bridge to a transplant. Moreover, patients who received treatment at combined LVAD/transplant centers were more likely to have a heart transplant within two years.
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| What You Should Know |
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| According to the study’s findings, the increased use of LVAD at nontransplant centers could contribute to inequities in patients’ access to heart transplant. Within two years, the transplant rate for patients who had received LVAD was 25.6% for LVAD/transplant centers, versus just 11.9% at LVAD-only facilities. The study authors note that recent Centers for Medicare & Medicaid Services policy changes, which remove the requirement to obtain review from a heart transplant center for LVAD implantation, could inadvertently increase inequities among patients’ access to heart transplant.
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| 2021 Coronary Revascularization Guidelines—Lessons in the Importance of Data Scrutiny and Reappraisal of Evidence |
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| The Story |
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| While the latest ACC/AHA/SCAI guidelines on coronary revascularization were released in December 2021, they have remained an ongoing source of debate into 2023. In a recent JAMA Surgery editorial, authors call into question the evidence upon which the downgrade of CABG relative to medical therapy in patients with stable ischemic heart disease and severe three-vessel disease was based, stating that many study conclusions contradict the guidelines. |
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| What You Should Know |
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| Many professional cardiovascular associations including AATS, STS, EACTS and LACES spoke up to question the change in recommendation for CABG in this group of patients when the guidelines were released. This current editorial review cites issues such as lack of randomization in trials and the fact that certain studies were given more weight arbitrarily. Specifically, CABG and PCI data was lumped together when creating the guidelines, despite the fact that the therapies are different. The 2021 guidelines may therefore serve as a reminder to closely review source documents instead of accepting summary evidence at face value.
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| Leadership Reflections |
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Grit: The Power of Passion and Perseverance
How long does it take to make a new behavior automatic? Some say it takes a consistent twenty-one days to form a new habit, while others believe it’s closer to three months. No matter the time frame, each habit formation starts with day one. Our potential is one thing, but how we act on it, is another.
Psychiatrist Angela Duckworth shares the secret characteristic of achieving long term goals in her TED talk, Grit: The Power of Passion and Perseverance. Indeed, grit is one of the most desirable traits of a leader. It is something everyone can learn as it does not rely on talent or I.Q., rather, it is determined by effort and consistency toward your goals. A leader with grit seeks inspiration in the face of adversity and has the power to create a culture centered on resilience. How does one become “gritty?” What does it take to grow your grit in leadership? Here are some core principles to consider:
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- Clarify your goals – Identify clear, simple goals to encourage focus.
- Discover your interest - Interest is your source of passion to keep the care-factor involved.
- Practice deliberately - Practice repetition with reflection and refinement.
- Find your “why?” – Discover your purpose.
- Use optimistic self-talk – If you think you can, you will.
- Create a gritty culture – Surround yourself with energy you want to identity with.
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| A leader with grit is contagious and uplifts those around them to stay relentless in their goals. I challenge you to grow your grit in 2023. |
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| AAPA Executive Leadership Conference |
| Mon. Mar. 6 - Wed. Mar. 8 |
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| The General Thoracic Surgical Club 2023 Annual Meeting |
| Thurs., Mar 9 - Sun., Mar 12 |
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| Houston Aortic Symposium |
| Thurs., Mar. 16 - Sat., Mar. 18 |
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| AmSECT 61st International Conference |
| Fri. Mar. 24 - Sun. Mar. 26 |
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