BACKGROUND Some observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoingcardiac surgery may be especially vulnerable to the adverse effects of transfusion. METHODS We conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge. RESULTS The median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, −0.6 to 0.3; P = 0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P = 0.43); 28-day mortality was 4.4% and 5.3%, respectively (P = 0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group. CONCLUSIONS The duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.)

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nhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. 1 These programs aim to reduce complications and promote an earlier return to normal activities. 2,3 The ERAS protocols have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management in populations having noncardiac surgery. 4-6 Evidence-based ERAS protocols have been published across multiple surgical specialties. 1 In early studies, the ERAS approach showed promise in cardiac surgery (CS); however, evidence-based protocols have yet to emerge. 7 To address the need for evidence-based ERAS protocols, we formed a registered nonprofit organization (ERAS Cardiac Society) to use an evidence-driven process to develop recommendations for pathways to optimize patient care in CS contexts through collaborative discovery, analysis, expert consensus, and best practices. The ERAS Cardiac Society has a formal collaborative agreement with the ERAS Society. This article reports the first expert-consensus review of evidence-based CS ERAS practices. Methods We followed the 2011 Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, using a standardized algorithm that included experts, key questions, subject champions, systematic literature reviews, selection and appraisal of evidence quality, and development of clear consensus recommendations. 8 We minimized repetition of existing guidelines and consensus statements and focused on specific information in the framework of ERAS protocols.

Although the incidence of sternal wound infections has decreased to 1% to 4% of all cardiac surgery procedures, they continue to be associated with increased morbidity and mortality, and decreased long-term life expectancy. [1][2][3] They prolong hospital length of stay and can raise hospital costs by as much as US$62,000. 4 Sternal wound infections are now publicly reported, and the US Center for Medicare and Medicaid services will no longer reimburse hospital costs incurred in the treatment of deep sternal wound infections (DSWI) following coronary artery bypass graft (CABG) surgery. 5 Despite the significant clinical and economic consequences of sternal wound infections, there are currently no specific guidelines in cardiac surgery for the prevention and treatment of sternal wound infections. What follows are recommendations for the prevention of wound infections during the preoperative, intraoperative, and postoperative periods, as well as principles for the most effective methods and techniques to treat sternal wound infections to achieve the lowest morbidity and mortality as derived from evidence-based recommendations (Tables 1 and 2). METHODSA literature search was performed using PubMed and Google Scholar up to March 2015 using the MeSH headings ''Sternal Wound Infections -Prevention and Treatment,'' ''Treatment of Mediastinitis,'' ''Topical Antibiotics in Cardiac Surgery,'' ''Wound VAC Therapy for Sternal Wound Infections,'' and ''Prevention and Treatment of Sternal Instability.'' Editorials and articles involving prevention and therapy for wound infections in noncardiac, nonsternotomy patients were excluded.The systemic review was reported according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines 6 (Figure 1).