Enhanced Recovery after Cardiac Surgery: An Update on Clinical Implications

Abstract

BackgroundTremendous changes have occurred in enhanced recovery after surgery (ERAS) since Danish surgeon Dr Kehlet published his landmark article in 1997, emphasizing that major surgical procedures may lead to significant undesirable sequelae, including infection, pain, hemorrhage, cardiopulmonary and thromboembolic complications, ileus, postoperative nausea and vomiting, fatigue, and prolonged convalescence. 1 In this regard, the surgical stress response and its subsequently increased demands on organ function is the critical factor influencing postoperative

Enhanced recovery after surgery (ERAS) in clinical practice

“…However, the ERAS protocols are all linked by a set of unifying objectives-the reduction in the stress response of patients to surgery and the speedy resumption of normal daily function. 1,3,7,11,[20][21][22][23] The attenuation of patient stress via ERAS is aimed at minimizing the postoperative catabolic state experienced by the patient, which can lead to the detrimental outcomes of insulin resistance, muscle loss, infection, and delays in wound and anastamotic healing, [20][21][22] inevitably leading to prolonged recovery and extended hospital stays and costs. ERAS protocols can be divided into three time points-preoperative, intraoperative, and postoperative; the key elements which unify the different ERAS guidelines will be discussed here.…”

“…50 It has been identified that careful attention to fluid balance is an especially important consideration during procedures such as cardiac surgery with cardiopulmonary bypass, where up to 2 L of priming fluid are routinely used, putting patients at an elevated risk for developing complications. 20 Current ERAS guidelines have even outlined the use of transesophageal doppler for the monitoring of patient fluids, in high-risk cases. 12,20…”

“…[10][11][12][13][14][15][16][17][18][19] This typically includes the preferential use of neuraxial anesthesia if not contraindicated and the avoidance of long-acting opioids and sedative/hypnotics in patients over 70. 20,22 The opioid abuse is the leading cause of overdose and death from prescription drugs, with concomitant benzodiazepine use acting as a prevalent contributor to opioid-related morbidity and mortality. 52 Moreover, the use of both benzodiazepines and opioids is associated with prolonged postoperative delirium in elderly patient populations.…”

“…[10][11][12][13][14][15][16][17][18][19] A unifying goal of these procedures is the drive to quickly return patients to normal daily function and mitigate the surgical stress and accompanied catabolic state, that have been attributed to cause a number of postoperative complications while delaying patient recovery. 1,3,7,11,[20][21][22][23] The contents of this review will focus on examining current evidence for ERAS pathways and discuss the implementation and associated obstacles to this much needed quality improvement.…”

The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials

“…ERAS is a multimodal, multidisciplinary initiative to improve perioperative care with the effect of substantial improvements in clinical outcomes and cost savings [ 21 ]. It is especially relevant to cardiac surgery and includes issues related to human nutrition and metabolism during the preoperative preparation (fasting, preoperative carbohydrate treatment), intraoperative management (blood glucose monitoring and treatment) and postoperative approach (treatment of nausea and vomiting, early nutrition and gastrointestinal stimulation) [ 22 , 24 , 25 , 26 , 27 ].…”