Presented as part of the Department of Cardiovascular Surgery Grand Rounds on February 20, 2019, by Fatma Abdelqader, MD, at the end of this video, viewers will be able to: • Develop events leading to mortality following cardiac surgery and any alternative approaches which may have changed outcomes Okay, I'd like to introduce dr Abdul Qadir, who is joined me on the quality team to lead our efforts to modify and implement the work that was started by DR ready doctor boating on cabbage pathways. Good morning everyone. My name is Fatima Abdulqader, I'm the performance improvement coordinator at the department. Now I'm going to give you a presentation about eras, which is gaining popularity in surgery around the world. It stands for enhancing recovery after surgery. So let's begin with the definition of Iraq. Iraq is a multi model, multidisciplinary peri operative approach to patients to achieve early recovery from surgery, especially major surgeries, enhances recovery, addresses the patient journey from the start in the doctor's office or impatient until discharge in the double 80 s last year in SAn Diego. Uh there was a dedicated session as regard Iraq in cardiac surgery and he came with the first ever consensus recommendations as you see here with different levels of evidences and if you have a look at the program of the double 80 S. Next in May, you will find some sessions talking about eras peri operative in cardiac surgery. So why Iraq in cardiac surgery there is a financial burden around the expanding expenditure in cardiac surgery as well as the increase in patient expectations, complexity in our case is growing elderly population making cardiac patients idea cohort for application of Iraq as there have been clinical trials that shows that well designed and well implemented. Iraq's protocol can assist in achieving good outcomes with less complications, less length of stay and less cost. With improved patient satisfaction. Iraq's will help us standardize our order sets to eliminate any variability in our practice as well as spreads the best practices as possible. So as you see in the slide, it's tho was the different components in Iraq which includes three main bundles. The first is preoperative from the patient referral until the operating room, intra operative components and post operative components. So here I'm going to highlight the most important components in each pillar in pre operative interventions. We will start by educating the patient and the family as regard the disease is a disease about the hospital course as well as the expectations in the hospital and the expected lines of state so that the patient well prepare himself very well before surgery and expect what's going to happen after that. The second important recommendation is assessment and optimization of any comorbidities before surgery. For example if the patient having anemia we have to correct it before surgery by supplementing the patient with iron or even getting a hematology, consult before surgery to reduce blood transfusions afterward and if the patient having high hemoglobin A one C we can refer to endocrinology to help us optimize the patient very well before surgery. For sure we have to start incentives parliamentary training to decrease post operative pulmonary complications and make the patient in the best shape before surgery. At the day of surgery the patient will be N. P. O. After midnight which is the same like what we are doing but Except for a carbohydrate, clear liquid loading two hours pre operatively. And the other thing that's new to the practice is initiation of multimodal opioid analgesia before surgery by giving the patient one oral dues of acetaminophen and or grab a clinton before induction of anesthesia. The intra operative interventions which will be provided by our surgical and anesthesia team will include fast track cardiac anesthesia protocol longer protective ventilation, blood conservation strategist. And we will continue that multi model opioid sparing analgesia, maintaining normal thermal and tied like semi control as per as per protocol. And we will initiate the postoperative nausea and vomiting prophylaxis in the operating room by giving the patient one intravenous dues of owned etc. Before the end of surgery and excavation of the patient is possible on table. Richard external fixation as indicated in certain patients to reduce the wound infection later on and give the patient more um more ability to move around and less pain. Post operative intervention will include early X. Situation. If the patient is not excavated in the O. R. And we will continue again the multi model opioid despairing analgesia. We will reserve the use of opioid for the cases of moderate to severe pain. And we would prefer oral versus intravenous uh way. We will continue the postoperative nausea, vomiting prophylaxis for the first post operative two days and we will encourage the patient to move from post operative day zero as well as early or a nutrition and for sure, early removal of any drains and catheters and the lorry. Um screening in the ICU at least once per nursing shift. An early discharge planning for areas protocol to be implemented, it can't be done except with good auditing for the compliance and the outcomes of application of our era's program. So what are our target patient population here? We will start working in our cabbage patients. Um The candidates will be identified and assigned for the pathway pre operatively in the clinic or impatient. Our exclusion criteria will be high risk patients and urgent emergent cabbage patients. So as you see here we will integrate the ERA's components after agreement of our faculty and the anesthesia team to our already existing cabbage pathway that dr Percy and DR ready and many others have worked it. Um Annette to summarize ERAs pathway in cabbage entails multidisciplinary team participation, which will include surgeons, anesthesia, intensive ist and nursing as well. We have to agree on a standardized order set, and we will create an epic pathway to integrate it into our system so it will be easy to audit the outcomes and the compliance to act. Thank you.