European Union of Private Hospitals

EPHA awards 2022 – Best model of clinical innovation

1st price, the IRCCS Policlinico San Donato, Italy, for developing the best anesthesia and intensive care treatment in cardiac surgery

The IRCCS Policlinico San Donato is the leading heart surgery centre in Italy, in terms of number and complexity of cases. This initiative aims at identifying and developing the best perioperative strategies to reduce the morbidity and mortality risk of adult patients undergoing cardiac surgery.

The outcome of cardiac surgery depends on the quality of the surgical performance. However, it is also strongly affected by complications that are not strictly related to the quality of surgery. Main determinants of these complications are: the preoperative risk profile of the patient; the effects of Cardiopulmonary bypass; the consequences of bleeding and transfusions; a combination of factors leading to organ dysfunction, prolonged Intensive Care Unit (ICU) stay, and accordingly the associated higher mortality rate to this latter. Therefore, the present initiative aims at developing a multi-factorial protocol of interventions to prevent and contain these adverse outcomes, having as ultimate goal the reduction of mortality in cardiac surgery.

Dott. Ranucci, father of the project

It is based on three levels of interventions:

  1. Preoperative: optimization of the patient conditions, through interventions aimed at modifying all the modifiable risk factors, with particular respect to the identification and treatment of preoperative anemia. Specific interventions applied are tailored to the type of anemia (iron supplementation and/or erythropoietin). Preoperative anemia is, indeed, a common feature in cardiac surgery and it is associated with a high risk of receiving RBC transfusions and experiencing morbidity and mortality events. Preoperative corrections of all the modifiable risk factors, among which anemia is probably one of the most relevant, should be prominent. Measurable objectives in this phase are the containment of both blood transfusions and shortening of Intensive Care Unit stay (ICU).
  2. Intraoperative: maintenance of an adequate hemodynamic and metabolic profile during Cardiopulmonary bypass (CPB), with particular respect to the containment of hemodilution and the maintenance of a correct oxygen delivery (DO2). Specific calculations based on on-line patients’ data are used to measure the quality of intraoperative perfusion. The measurable objective in this phase is the containment of postoperative organ dysfunction, with particular respect to acute kidney injury.
  3. Postoperative: application of a tailored strategy for the treatment of postoperative bleeding, based on an algorithm developed by our Institution and patient-specific interventions. These interventions include the use of pro-coagulants (prothrombin complex concentrate; fibrinogen concentrate; desmopressin; tranexamic acid; and others) to reduce the need for allogeneic blood products. The measurable objective here is the containment of blood transfusions.