One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program

Abstract

Objective: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States.Methods: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre-and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.Results: Comparing the pre-(N ¼ 489) with the post-(N ¼ 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P <.01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P <.01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P <.05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P <.01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P ¼ not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.Conclusions: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.

Remifentanil and sevoflurane based anesthesia combined with bilateral erector spinae plane block in patients undergoing off-pump coronary artery bypass graft surgery

“…This was a prospective, open-label, observational study aiming to compare the newly introduced ERAS Cardio protocol with the standard of care in patients undergoing OP-CABG. We have demonstrated several benefits associated with the use of the enhanced General anesthesia with high doses of fentanyl seems to be the most commonly used analgesic option in a vast majority of cardiac patients worldwide [7][8][9]. Remifentanil, which is routinely used in ASA physical status groups III and IV, i.e.…”

Effects of Preoperative Oral Carbohydrate on Cirrhotic Patients Under Endoscopic Therapy with Anesthesia: A Randomized Controlled Trial

“…Based mainly on recommendations issued by ERAS societies, the current guideline for preoperative fasting is 6 h for solid foods and 2 h for clear uids (13). Preoperative oral carbohydrates (POC), avoiding preoperative fasting by oral intake of a carbohydrate uid is widely adopted as part of ERAS protocol that has shown bene cial effect on improving perioperative well-beings and clinical outcomes of patients (14). Although several studies have reported POC, with high energy content, does not pose any threat from vomiting or aspiration when taken 2 h before anesthesia in patients undergoing elective surgery (15,16), there is lack of evidence about the effect of POC on some individual constituents with a propensity for delayed gastric emptying, including cirrhotic patients (17).…”

Commentary: The power of the pen—cardiac surgical opioid use in the United States

“…5,6 A recent publication in the Journal demonstrated that an enhanced recovery after cardiac surgery program (ie, ERAS) significantly reduced opioid use in the postoperative period. 7 While compelling, the study is not without limitations. The study is retrospective in nature and the database was limited to patients with private insurance (38% of patients undergoing CABG in the United States) without including Medicare, Medicaid, or uninsured patients, which represents a selection bias potentially affecting opioid-use patterns in the data analyzed and presented.…”