Enhanced Recovery Pathways for Cardiac Surgery

Abstract

Purpose of Review Enhanced recovery after surgery (ERAS) has become a widespread topic in perioperative medicine over the past 20 years. The goals of ERAS are to improve patient outcomes and perioperative experience, reduce length of hospital stay, minimize complications, and reduce cost. Interventions and factors before, during, and after surgery all potentially play a role with the cumulative effect being superior quality of patient care. Recent Findings Preoperatively, patient and family education, optimization of nutritional status, and antibiotic prophylaxis all improve outcomes. Recovery is also expedited by the use of multimodal analgesia, regional anesthesia, and opioid reducing approaches. Intraoperatively, the anesthesiologist can have an impact by using less-invasive monitors appropriately to guide fluid and hemodynamic management as well as maintaining normothermia. Postoperatively, early enteral feeding, mobilization, and removal of invasive lines support patient recovery. Implementation of ERAS protocol in cardiac surgery faces challenges by some unique perioperative perspectives in cardiac surgery, such as systemic anticoagulation, use of cardiopulmonary bypass, significantly more hemodynamic variations, larger volume replacement, postoperative intubation and mechanical ventilation and associated sedation, and potentially significantly more coexisting morbidities than other surgical procedures. Summary ERAS in cardiac surgery may benefit patients more related to its high risk and high cost nature. This manuscript specifically reviews the unique aspects of enhanced recovery in cardiac surgery.

Risk of Prolonged Mechanical Ventilation After Cardiac Surgery: Predicting the Unpredictable?

“…Moreover, modern cardiac anesthesia and cardiac intensive care include enhanced recovery pathways with specific focus on optimized patient management techniques (ie, improvement of preoperative nutritional status, intraoperative normothermia, multimodal analgesia regime) and multidisciplinary clinical pathways (eg, fast-track anesthesia). 8,9 They overall positive effect on duration of postoperative mechanical ventilation is indisputable. Similarly, increasing utilization of cytokine absorbers may reduce high levels of inflammatory markers, and hemodynamic management with new drugs (eg, levosimendan, milrinone) and tools (eg, echocardiography, continuous cardiac output monitoring) may lead to a reduced incidence of postoperative cardiogenic shock and associated high arterial lactate levels despite of a prolonged cardiopulmonary bypass time.…”

Persistent Pain After Cardiac Surgery: Prevention and Management

“…ERAS pathways including those specific to cardiac surgery continue to gain popularity and aim to incorporate multiple objective variables to optimize patient experience, perioperative efficiency, and improve outcomes. 76 - 79 Multimodal analgesia has remained central to ERAS protocols as this strategy may offer decreased opioid exposure in addition to potentially reducing recovery times, complications, and improving cost expenditures with surgery. 62 , 80 , 81 Similarly, regional anesthesia has been increasingly implemented as part of a multimodal strategy in cardiac surgery and related ERAS protocols to reduce opioid consumption.…”

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

“…One of the measures to improve post-operative outcome is oral carbohydrate loading (OCH) treatment, initiated to optimize the nutritional status of the patient prior to elective surgery as part of the Enhanced Recovery After Surgery (ERAS) pathway [ 21 , 22 , 23 ]. ERAS is a multimodal, multidisciplinary initiative to improve perioperative care with the effect of substantial improvements in clinical outcomes and cost savings [ 21 ].…”

“…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 ].…”