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In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes.

This chapter discusses the importance of cardiac surgical risk scoring models in classifying risk in adult patients. These scores first came into construct in the 1980s when the rate of mortality following coronary bypass graft surgery began to increase. Since this time, numerous scoring systems have been developed to define patient risk factors. The first widely used risk model was the initial Parsonnet score developed in 1989, which predicted cardiac surgical mortality based on preoperative risk factors thought to be clinically significant. Today, the most commonly used risk assessment tools for cardiac surgical patients are the European System for Cardiac Operative Risk Evaluation II and the Society of Thoracic Surgeons risk score. However, neither of these 2 major scoring systems assesses frailty. Frailty is consistently associated with a greater risk of morbidity and mortality in patients undergoing transcatheter aortic valve replacement procedures. The risk associated with frailty following open cardiac surgical procedures is less clear.

Nonopioid adjuvant medications are increasingly included among perioperative Enhanced Recovery After Surgery protocols. Preoperative pregabalin has been shown to improve postoperative pain and limit reliance on opioid analgesia. Our group investigated the ability of preoperative pregabalin to also prevent postoperative nausea and vomiting (PONV).Our group performed a meta-analysis of randomized trials that report outcomes on the effect of preoperative pregabalin on PONV endpoints in patients undergoing general anesthesia.Among all included trials (23 trials; n = 1693), preoperative pregabalin was associated with a significant reduction in PONV (risk ratio [RR] = 0.53; 95% confidence interval [CI], 0.39-0.73; P = 0.0001), nausea (RR = 0.62; 95% CI, 0.46-0.83; P = 0.002), and vomiting (RR = 0.68; 95% CI, 0.52-0.88; P = 0.003) at 24 hours. Subgroup analysis designed to account for major PONV confounders, including the exclusion trials with repeat dosing, thiopental induction, nitrous oxide maintenance, and prophylactic antiemetics and including high-risk surgery, resulted in similar antiemetic efficacy. Preoperative pregabalin is also associated with significantly increased rates of postoperative visual disturbance (RR = 3.11; 95% CI, 1.34-7.21; P = 0.008) compared with a control.Preoperative pregabalin is associated with significant reduction of PONV and should not only be considered as part of a multimodal approach to postoperative analgesia but also for prevention of PONV.

Energy communication networks (ECNs) play an integral role in electrical substations. Substations host many Intelligent Electronic Devices (IEDs) that monitor the state of the electricity infrastructure. This critical data is packaged and transmitted between multiple IEDs for proper system monitoring and control. The modern network that interconnects IEDs, while a significant improvement over the historic serial interconnection, has many challenges which have yet to be addressed - ranging from setup complexity to security policies. In this paper we propose that software-defined networking can alleviate many of today's problems and create a network which can evolve with changing technologies and needs. We demonstrate an auto-configuring substation network which eliminates many substation network management issues. Our prototype is built using a Ryu-based, software-defined network controller and tested with actual IEDs used in substations. We also discuss how our software-defined energy communication network (SDECN) architecture not only solves problems of today, but enables substation networks to easily evolve with the rapid evolution of the smart grid.