Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step—But There Is Much Work to Be Done

Published:September 28, 2019DOI:https://doi.org/10.1053/j.jvca.2019.09.002
      ENHANCED RECOVERY After Surgery (ERAS) is an international effort to develop perioperative programs aimed at optimizing patient outcomes and healthcare delivery efficiency. These programs are composed of intervention bundles based on the principles of best practice, standardized and consistent healthcare delivery, regular audit, and team feedback, all with a patient-centered focus. Implementation of such programs has resulted in patient and healthcare benefits, including promising early results within the cardiac surgical community.
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      Aggregation of marginal gains in cardiac surgery: Feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients.
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      Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: A randomized clinical trial.
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      One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.
      There have been recent concerns that old dogma, typically rooted in clinical anecdotes and minimal peer-reviewed evidence, will be replaced with new dogma under the umbrella of “enhanced recovery” without validation in cardiac surgical patients.
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      • Poeran J.
      • Kehlet H.
      Enhanced recovery after surgery in the United States: From evidence-based pactice to uncertain science?.
      An imprudent “changing of the guard” is a justifiable concern with any practice update. Gathering current evidence-based best practices was a key motivation for the creation of the original colorectal ERAS protocol.
      The Society for Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) recently published “Guidelines for Perioperative Care in Cardiac Surgery” based on a systematic review and multidisciplinary consensus.
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      • Williams J.B.
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      Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations [E-pub ahead of print].
      Twenty-two recommendations were graded according to currently accepted standards for level of evidence (LOE) and confidence of recommendation (COR) (Table 1).
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      The authors of this editorial represent the current anesthesiologist membership of the ERAS Cardiac Society. We have chosen a subset of the recommendations to discuss, including why each is important for patients during their recovery and which future steps are required to solidify the supporting evidence for each recommendation.
      Table 1Summary of Grading Used for ERAS Cardiac Recommendations, in Accordance With the American Association for Thoracic Surgery, Society of Thoracic Surgeons, American College of Cardiology, and American Heart Association
      • Bakaeen F.G.
      • Svensson L.G.
      • Mitchell J.D.
      • et al.
      The American Association for Thoracic Surgery/Society of Thoracic Surgeons position statement on developing clinical practice documents.
      ,
      • Jacobs A.K.
      • Anderson J.L.
      • Halperin J.L.
      • et al.
      The evolution and future of ACC/AHA clinical practice guidelines: A 30-year journey: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.
      Class (Strength) of RecommendationLevel (Quality) of Evidence
      Class I (strong)Level A
      Class IIa (moderate)Level B-R (randomized)
      Class IIb (weak)Level B-NR (nonrandomized)
      Class III: no benefit (moderate)Level C-LD (limited data)
      Class III: harm (strong)Level C-EO (expert opinion)

      A Care Bundle of Evidence-Based Best Practices to Reduce Surgical Site Infections (LOE: I/COR: B-R)

      The reported incidence of deep sternal wound infection (DSWI) ranges between 0.8% and 6.0%, and DSWI is associated with prolonged hospital stays, long-term antibiotic therapy, repeated surgical procedures, higher morbidity/mortality, increased patient suffering, and higher healthcare costs.
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      • Russo M.
      • Cheema F.H.
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      Risk analysis of deep sternal wound infections and their impact on long-term survival: A propensity analysis.
      • Eklund A.M.
      • Lyytikainen O.
      • Klemets P.
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      Mediastinitis after more than 10,000 cardiac surgical procedures.
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      Poststernotomy mediastinitis: A review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm.
      • Tang A.T.
      • Ohri S.K.
      • Haw M.P.
      Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection.
      Predisposing factors known to be associated with DSWI include obesity, diabetes, coronary artery disease, low ejection fraction, chronic steroid therapy, chronic infections, end-stage renal disease, smoking, and advanced age.
      • Centofanti P.
      • Savia F.
      • La Torre M.
      • et al.
      A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery. An updated risk factor analysis.
      • Lemaignen A.
      • Birgand G.
      • Ghodhbane W.
      • et al.
      Sternal wound infection after cardiac surgery: Incidence and risk factors according to clinical presentation.
      • Ridderstolpe L.
      • Gill H.
      • Granfeldt H.
      • et al.
      Superficial and deep sternal wound complications: Incidence, risk factors and mortality.
      • Robinson P.J.
      • Billah B.
      • Leder K.
      • et al.
      Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria.
      Surgical factors that are believed to contribute to the development of DSWIs include inadequate skin preparation, use of bone wax, emergency surgeries, bilateral harvesting of the internal mammary artery, blood product transfusion, prolonged bypass or surgical time, sternal rewiring, and postoperative bleeding.
      • Cutrell J.B.
      • Barros N.
      • McBroom M.
      • et al.
      Risk factors for deep sternal wound infection after cardiac surgery: Influence of red blood cell transfusions and chronic infection.
      ,
      • Schiraldi L.
      • Jabbour G.
      • Centofanti P.
      • et al.
      Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery.
      Efforts should be focused on addressing modifiable risk factors (eg, perioperative management of glucose levels, enhanced nutritional support, and ensuring that the patient receives the appropriate antibiotics within the optimal window).
      • van den Boom W.
      • Schroeder R.A.
      • Manning M.W.
      • et al.
      Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries.
      ,
      • Allegranzi B.
      • Bischoff P.
      • de Jonge S.
      • et al.
      New WHO recommendations on preoperative measures for surgical site infection prevention: Anevidence-based global perspective.
      Several components of a bundle to reduce surgical-site infections have been previously identified.
      • Lazar H.L.
      • Salm T.V.
      • Engelman R.
      • et al.
      Prevention and management of sternal wound infections.
      The role of an ERAS Cardiac program may be to augment compliance by leveraging local human and electronic infrastructure, including audit and feedback, as a platform to implement a protocol that is applied consistently.

      Goal-Directed Fluid Therapy (LOE: I/COR: B-NR)

      Since the inception of enhanced recovery programs, we have witnessed a swinging pendulum— recognition of the detrimental effects of excessive intravenous fluids followed by subsequent indications that overly restrictive fluid administration might be even more harmful.
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      • Noorani A.
      • Varty K.
      • et al.
      Perioperative fluid restriction in major abdominal surgery: Systematic review and meta-analysis of randomized, clinical trials.
      • Brandstrup B.
      • Tonnesen H.
      • Beier-Holgersen R.
      • et al.
      Effects of intravenous fluid restriction on postoperative complications: Comparison of 2 perioperative fluid regimens: A randomized assessor-blinded multicenter trial.
      • Lobo D.N.
      • Bostock K.A.
      • Neal K.R.
      • et al.
      Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: A randomised controlled trial.
      • Myles P.S.
      • Bellomo R.
      • Corcoran T.
      • et al.
      Restrictive versus liberal fluid therapy for major abdominal surgery.
      • Nisanevich V.
      • Felsenstein I.
      • Almogy G.
      • et al.
      Effect of intraoperative fluid management on outcome after intraabdominal surgery.
      Goal-directed therapy (GDT) is an algorithmic approach, guided by specialized monitoring devices, to individualize the use of intravenous fluids, vasopressors, and inotropes to achieve specific hemodynamic goals, thereby optimizing oxygen delivery and organ perfusion.
      • Corcoran T.
      • Rhodes J.E.
      • Clarke S.
      • et al.
      Perioperative fluid management strategies in major surgery: A stratified meta-analysis.
      ,
      • Dalfino L.
      • Giglio M.T.
      • Puntillo F.
      • et al.
      Haemodynamic goal-directed therapy and postoperative infections: Earlier is better. A systematic review and meta-analysis.
      Theoretically, GDT represents a significant improvement from more traditional or intuition-based fluid strategies, particularly when hemodynamic instability or cardiopulmonary dysfunction clouds the clinical picture.
      In the noncardiac surgical population, GDT has been associated with reduced postoperative complication rates and length of stay.
      • Corcoran T.
      • Rhodes J.E.
      • Clarke S.
      • et al.
      Perioperative fluid management strategies in major surgery: A stratified meta-analysis.
      • Dalfino L.
      • Giglio M.T.
      • Puntillo F.
      • et al.
      Haemodynamic goal-directed therapy and postoperative infections: Earlier is better. A systematic review and meta-analysis.
      • Sun Y.
      • Chai F.
      • Pan C.
      • et al.
      Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials.
      Whereas GDT may provide benefit in high-risk patients and/or procedures, it is less likely to do so for healthy patients undergoing low-risk or routine laparoscopic procedures.
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      • et al.
      Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: A randomized controlled trial.
      ,
      • Thiele R.H.
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      • Brudney C.S.
      • et al.
      American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery.
      Furthermore, as hospitals incorporate other enhanced recovery elements (eg, liberation of prolonged fasting, carbohydrate loading, early enteral feeding), the effect of GDT may be diminished.
      • Gomez-Izquierdo J.C.
      • Feldman L.S.
      • Carli F.
      • et al.
      Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery.
      ,
      • Rollins K.E.
      • Lobo D.N.
      Intraoperative goal-directed fluid therapy in elective major abdominal surgery: A meta-analysis of randomized controlled trials.
      Because of its inherent high-risk nature and the recently growing interest in enhanced recovery principles, cardiac surgery represents an ideal opportunity to incorporate GDT. Preliminary data are encouraging, with several prospective trials demonstrating reduced 30-day complications, acute kidney injury (AKI), and hospital length of stay compared with conventional care.
      • Aya H.D.
      • Cecconi M.
      • Hamilton M.
      • et al.
      Goal-directed therapy in cardiac surgery: A systematic review and meta-analysis.
      • Goepfert M.S.
      • Richter H.P.
      • Zu Eulenburg C.
      • et al.
      Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: A prospective, randomized controlled trial.
      • Osawa E.A.
      • Rhodes A.
      • Landoni G.
      • et al.
      Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac surgery: A randomized clinical trial and systematic review.
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      • Valencia O.
      • et al.
      Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury.
      The universal applicability of these results is unclear; our current state-of-evidence is based on small trials with shortcomings that include different hemodynamic and resuscitative targets, measuring composite outcomes with inconsistent definitions, and using algorithms not validated against a gold standard (in part, because one may not exist). The result is a well-intentioned, resource-intensive strategy that to date has produced outcomes that are challenging to interpret, as witnessed in the equivocal pooled results of a recent meta-analysis.
      • Li P.
      • Qu L.P.
      • Qi D.
      • et al.
      Significance of perioperative goal-directed hemodynamic approach in preventing postoperative complications in patients after cardiac surgery: A meta-analysis and systematic review.
      In cardiac surgery, during which blood loss and volume shifts are difficult, if not impossible, to track with current technology, coupled with the lack of clear evidence for the success of GDT, it is clear that more work is necessary. It will be important to establish the appropriate overarching objectives, optimal device characteristics, and specific strategies necessary to exact the desired benefits of GDT.

      A Perioperative, Multimodal, Opioid-Sparing, Pain Management Plan (LOE: I/COR: B-NR)

      Despite limited experience or evidence in cardiac surgical patients, the guidelines recommended the implementation of a multimodal opioid-sparing analgesic regimen for the treatment of postoperative pain. This is likely justifiable given the higher quality of evidence and positive results in noncardiac surgical populations.
      • Noss C.
      • Prusinkiewicz C.
      • Nelson G.
      • et al.
      Enhanced recovery for cardiac surgery.
      Furthermore, the recognition that overprescription of opioids may contribute to the international opioid epidemic has made adoption of multimodal opioid-sparing analgesic strategies a priority in the medical community. Simple transference of noncardiac multimodal bundles to cardiac surgery has several limitations, including unique considerations in our patients regarding medical comorbidities, complex perioperative pharmacokinetic/pharmacodynamics, and different cost/benefit and risk/benefit analyses. For example, the analgesic efficacy of nonsteroidal anti-inflammatory drugs must be weighed against the risk of AKI and bleeding, thromboembolic, and gastrointestinal complications. The analgesic regimen also should be designed to minimize the risk of delirium and facilitate early rehabilitation and convalescence. Intravenous acetaminophen and a variety of regional anesthesia techniques have shown promise, but additional work is needed to determine their true effectiveness and whether they should be applied to all patients or only a select few. The current state of multimodal analgesia in cardiac surgery is in flux, with different approaches used globally and little evidence to guide the optimal therapeutic method. Improved analgesia, reduced side-effects, and using the lowest amount of opioid required for comfort are central to enhancing patients’ recovery. The ERAS Cardiac Society's grading of this recommendation is appropriate because it is a laudable goal that requires additional research. Areas of investigation to refine postoperative pain management include the following: managing patient and provider expectations, individualizing the dose and types of analgesics, consideration of the potential cardioprotective effects of opioids, and incorporating nonpharmacologic approaches to pain management such as regional anesthesia.
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      Regional techniques for cardiac and cardiac-related procedures.
      ,
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      Delta opioid receptors and cardioprotection.

      Avoidance of Persistent Hypothermia (<36.0°C) After Cardiopulmonary Bypass in the Early Postoperative Period (LOE: I/COR: B-NR)

       Hyperthermia (>37.9°C) While Rewarming During Cardiopulmonary Bypass (LOE: III (Harm)/COR: B-R)

      Prolonged postoperative hypothermia has been associated with increased mortality after cardiac surgery.
      • Karalapillai D.
      • Story D.
      • Hart G.K.
      • et al.
      Postoperative hypothermia and patient outcomes after elective cardiac surgery.
      Additional complications, such as increased risk of infection, bleeding, and length of hospitalization, have been shown consistently in the noncardiac surgical population.
      • Frank S.M.
      • Fleisher L.A.
      • Breslow M.J.
      • et al.
      Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.
      • Kurz A.
      • Sessler D.I.
      • Lenhardt R.
      Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
      • Rajagopalan S.
      • Mascha E.
      • Na J.
      • et al.
      The effects of mild perioperative hypothermia on blood loss and transfusion requirement.
      The best way to prevent postoperative hypothermia is to maintain intraoperative euthermia, but there is contradictory retrospective evidence on the safety of this practice.
      • Greason K.L.
      • Kim S.
      • Suri R.M.
      • et al.
      Hypothermia and operative mortality during on-pump coronary artery bypass grafting.
      ,
      • Ho K.M.
      • Tan J.A.
      Benefits and risks of maintaining normothermia during cardiopulmonary bypass in adult cardiac surgery: A systematic review.
      Further complicating management is the requirement of deliberate hypothermia during cardiopulmonary bypass (CPB) and even deep hypothermic circulatory arrest to provide neuroprotection for certain procedures. Rewarming has the potential for harm if performed too quickly or if hyperthermia occurs, with an associated increased risk of postoperative cognitive defects, infection, and renal dysfunction.
      • Engelman R.
      • Baker R.A.
      • Likosky D.S.
      • et al.
      The Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, and the American Society of ExtraCorporeal Technology: Clinical practice guidelines for cardiopulmonary bypass—temperature management during cardiopulmonary bypass.
      Precision temperature management for cardiac surgical patients will require an improved understanding of the optimal temperatures that are effective for organ protection during CPB. Furthermore, research and standardization of optimal temperature sites will assist clinicians to accurately measure regional and systemic temperatures, improve the ability to prevent hyperthermia during rewarming, and predict temperature after-drop in the postoperative period.

      Postoperative Systematic Delirium Screening Tool Use at Least Once per Nursing Shift (LOE: I/COR: B-NR)

      Delirium increases complication rates, duration of mechanical ventilation, and morbidity and mortality and has been associated with long-term cognitive changes.
      • Ely E.W.
      • Shintani A.
      • Truman B.
      • et al.
      Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.
      • Mehta S.
      • Cook D.
      • Devlin J.W.
      • et al.
      Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults.
      • Nomura Y.
      • Nakano M.
      • Bush B.
      • et al.
      Observational study examining the association of baseline frailty and postcardiac surgery delirium and cognitive change.
      Preliminary data even have suggested that the presence of delirium is more important than the severity of illness in predicting intensive care unit length of stay.
      • Ely E.W.
      • Gautam S.
      • Margolin R.
      • et al.
      The impact of delirium in the intensive care unit on hospital length of stay.
      Delirium in the postoperative phase of cardiac surgical care occurs in all ages, affecting between 20% and 80% of patients.
      • Ely E.W.
      • Shintani A.
      • Truman B.
      • et al.
      Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.
      ,
      • Heymann A.
      • Radtke F.
      • Schiemann A.
      • et al.
      Delayed treatment of delirium increases mortality rate in intensive care unit patients.
      • Koster S.
      • Oosterveld F.G.
      • Hensens A.G.
      • et al.
      Delirium after cardiac surgery and predictive validity of a risk checklist.
      • Pandharipande P.P.
      • Girard T.D.
      • Jackson J.C.
      • et al.
      Long-term cognitive impairment after critical illness.
      Standardized and consistent identification of its presence is an important first step in the management of delirium and facilitating future research into its prevention. The risk of developing delirium postoperatively depends on multiple factors that include frailty, genetics, lifestyle, underlying diseases, drug therapy, surgical trauma, anesthesia management (including the use of benzodiazepines), venous congestion, and pain management, among others.
      • Aldecoa C.
      • Bettelli G.
      • Bilotta F.
      • et al.
      European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium.
      • Baron R.
      • Binder A.
      • Biniek R.
      • et al.
      Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.
      • Devlin J.W.
      • Skrobik Y.
      • Gelinas C.
      • et al.
      Executive summary: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
      • Pandharipande P.
      • Shintani A.
      • Peterson J.
      • et al.
      Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.
      • Radtke F.M.
      • Franck M.
      • Hagemann L.
      • et al.
      Risk factors for inadequate emergence after anesthesia: Emergence delirium and hypoactive emergence.
      • Radtke F.M.
      • Franck M.
      • Lendner J.
      • et al.
      Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction.
      • Benkreira A.
      • Beaubien-Souligny W.
      • Mailhot T.
      • et al.
      Portal hypertension is associated with congestive encephalopathy and delirium after cardiac surgery.
      Published guidelines recommend screening patients routinely for known risk factors.
      • Baron R.
      • Binder A.
      • Biniek R.
      • et al.
      Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.
      ,
      • Pandharipande P.P.
      • Sanders R.D.
      • Girard T.D.
      • et al.
      Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: An a priori-designed analysis of the MENDS randomized controlled trial.
      Diagnosis can be challenging, hence the benefit of patient assessments using valid and reliable delirium scales.
      • Luetz A.
      • Heymann A.
      • Radtke F.M.
      • et al.
      Different assessment tools for intensive care unit delirium: Which score to use?.
      ,
      • Neufeld K.J.
      • Leoutsakos J.S.
      • Sieber F.E.
      • et al.
      Evaluation of 2 delirium screening tools for detecting post-operative delirium in the elderly.
      Pharmacologic prevention with haloperidol or ketamine has not demonstrated benefit in large-scale clinical trials.
      • Avidan M.S.
      • Maybrier H.R.
      • Abdallah A.B.
      • et al.
      Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: An international, multicentre, double-blind, randomised clinical trial.
      ,
      • van den Boogaard M.
      • Slooter A.J.C.
      • Bruggemann R.J.M.
      • et al.
      Effect of haloperidol on survival among critically ill adults with a high risk of delirium: The REDUCE randomized clinical trial.
      Evidence suggests that the use of atypical antipsychotics, haloperidol, or a statin does not affect the duration of delirium or its related morbidity.
      • Devlin J.W.
      • Skrobik Y.
      • Gelinas C.
      • et al.
      Executive summary: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
      Encouraging data are emerging regarding the use of alpha-2 adrenergic agonists, such as dexmedetomidine.
      • Devlin J.W.
      • Skrobik Y.
      • Gelinas C.
      • et al.
      Executive summary: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
      ,
      • Skrobik Y.
      • Duprey M.S.
      • Hill N.S.
      • et al.
      Low-dose nocturnal dexmedetomidine prevents ICU delirium. A randomized, placebo-controlled trial.
      Nonpharmacologic strategies such as early mobilization; pain management; minimization and targeted titration of sedation; avoidance of benzodiazepines and restraints; patient reorientation; cognitive stimulation; reduction of hearing and/or visual impairment (eg, enable use of devices such as hearing aids or eyeglasses); use of clocks/calendars; and promotion of normal sleep-wake circadian pattern have shown promising results.
      • Devlin J.W.
      • Skrobik Y.
      • Gelinas C.
      • et al.
      Executive summary: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
      ,
      • Blair G.J.
      • Mehmood T.
      • Rudnick M.
      • et al.
      Nonpharmacologic and medication minimization strategies for the prevention and treatment of ICU delirium: A narrative review.
      • Brummel N.E.
      • Girard T.D.
      • Ely E.W.
      • et al.
      Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The Activity and Cognitive Therapy in ICU (ACT-ICU) trial.
      • Smith C.D.
      • Grami P.
      Feasibility and effectiveness of a delirium prevention bundle in critically ill patients.
      Delirium is a multifactorial disease, requiring an interdisciplinary team approach to prevention, diagnosis, risk stratification, and treatment. By implementing a standardized delirium screening tool, cardiac surgical centers will provide invaluable information to assist in future studies required to identify high-quality interventions to avoid a complication that carries a substantial effect on the quality of patients’ care and recovery.

      Early Detection of Kidney Stress and Interventions to Avoid Acute Kidney Injury After Surgery (LOE: IIa/COR: B-R)

      AKI is a well-documented complication after cardiac surgery and results in an increased risk of both morbidity and mortality.
      • Hobson C.E.
      • Yavas S.
      • Segal M.S.
      • et al.
      Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery.
      ,
      • Hu J.
      • Chen R.
      • Liu S.
      • et al.
      Global incidence and outcomes of adult patients with acute kidney injury after cardiac surgery: A systematic review and meta-analysis.
      Depending on the complexity of the procedure and the definition of AKI chosen, the reported incidence varies from 22% to 36%.
      • Hobson C.E.
      • Yavas S.
      • Segal M.S.
      • et al.
      Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery.
      ,
      • Hu J.
      • Chen R.
      • Liu S.
      • et al.
      Global incidence and outcomes of adult patients with acute kidney injury after cardiac surgery: A systematic review and meta-analysis.
      Severe AKI requiring renal replacement therapy occurs in 2% to 5% of cardiac surgical patients and has an associated mortality of 50% to 80%.
      • Hobson C.E.
      • Yavas S.
      • Segal M.S.
      • et al.
      Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery.
      ,
      • Hu J.
      • Chen R.
      • Liu S.
      • et al.
      Global incidence and outcomes of adult patients with acute kidney injury after cardiac surgery: A systematic review and meta-analysis.
      The Kidney Disease: Improving Global Outcomes criteria use serum creatinine and/or urine output for diagnosis and staging of AKI, although these 2 measures have limitations as functional biomarkers.
      Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group KDIGO Clinical Practice Guideline for Acute Kidney Injury.
      Recent advancements in early detection of kidney injury include use of urinary biomarkers (such as insulin-like growth factor–binding protein 7 and tissue inhibitor of metalloproteinases-2) that can detect stress/injury without requiring concurrent loss of kidney function.
      • Ronco C.
      • Kellum J.A.
      • Haase M.
      Subclinical AKI is still AKI.
      Previous studies have shown that elevated urinary biomarkers in cardiac surgical patients, either during or immediately after CPB, can identify those at increased risk for developing postoperative AKI.
      • Cummings J.J.
      • Shaw A.D.
      • Shi J.
      • et al.
      Intraoperative prediction of cardiac surgery-associated acute kidney injury using urinary biomarkers of cell cycle arrest.
      ,
      • Meersch M.
      • Schmidt C.
      • Van Aken H.
      • et al.
      Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery.
      The PrevAKI Trial, a prospective randomized controlled trial, used a biomarker-based approach to selectively apply a renal-protective bundle in high-risk cardiac surgical patients at risk for AKI, a result that requires confirmation in a large multicenter trial.
      • Meersch M.
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      • et al.
      Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: The PrevAKI randomized controlled trial.
      Additional research will be needed to standardize the reporting of AKI, better define the benefit of biomarker-guided interventions, examine cost-effectiveness, and investigate the risk assessment capabilities of other modalities, such as ultrasound quantification of renal congestion.
      • Beaubien-Souligny W.
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      Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: A prospective observational cohort study.

      Prehabilitation for Patients Undergoing Elective Surgery With Multiple Comorbidities or Significant Deconditioning (LOE: IIa/COR: B-NR)

      Cardiac prehabilitation, or “prehab,” includes a number of initiatives (eg, aerobic exercise training, respiratory muscle training, smoking cessation, decreasing alcohol consumption, improving sleep patterns, weight control, optimization of medical comorbidities, and psychosocial assessment and education).
      • McCann M.
      • Stamp N.
      • Ngui A.
      • et al.
      Cardiac prehabilitation.
      The primary goal of prehab is to reduce both the incidence and severity of postoperative complications.
      • Arthur H.M.
      • Daniels C.
      • McKelvie R.
      • et al.
      Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial.
      The interest in cardiac prehab itself has been driven by the need to address the increasing age, frailty, and comorbidities of patients about to undergo cardiac surgery.
      • Wang W.
      • Bagshaw S.M.
      • Norris C.M.
      • et al.
      Association between older age and outcome after cardiac surgery: A population-based cohort study.
      Older patients develop more postoperative complications and experience increased hospital length of stay and significantly greater 30-day mortality than their younger counterparts. Frailty (defined as reduced muscle mass weakness, low activity levels, and self-reported fatigue) increases the vulnerability to stressors because of a reduced multiorgan reserve.
      • McCann M.
      • Stamp N.
      • Ngui A.
      • et al.
      Cardiac prehabilitation.
      ,
      • Chen X.
      • Mao G.
      • Leng S.X.
      Frailty syndrome: An overview.
      Increased cardiorespiratory fitness is associated with decreased mortality, but physicians and patients may be apprehensive about prescribing an exercise program before cardiac surgery, paradoxically leading to increased sedentary behaviors and greater frailty.
      Cardiac surgery induces a systemic inflammatory response associated with increased oxygen consumption in the immediate postoperative period.
      • Older P.
      • Smith R.
      Experience with the preoperative invasive measurement of haemodynamic, respiratory and renal function in 100 elderly patients scheduled for major abdominal surgery.
      ,
      • Shoemaker W.C.
      • Appel P.L.
      • Kram H.B.
      Role of oxygen debt in the development of organ failure sepsis, and death in high-risk surgical patients.
      Patients with poor cardiopulmonary reserve will be less able to sustain these increased demands, leading to avoidable morbidity and mortality.
      • Boyd O.
      • Grounds R.M.
      • Bennett E.D.
      A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients.
      In selected patients awaiting cardiac surgery, a structured physical activity program designed to improve preoperative aerobic capacity is safe and may lead to a decrease in postoperative complications and hospital length of stay.
      • Marmelo F.
      • Rocha V.
      • Moreira-Goncalves D.
      The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: Systematic review and meta-analysis.
      • Sandhu M.S.
      • Akowuah E.F.
      Does prehabilitation improve outcomes in cardiac surgical patients?.
      • Sawatzky J.A.
      • Kehler D.S.
      • Ready A.E.
      • et al.
      Prehabilitation program for elective coronary artery bypass graft surgery patients: A pilot randomized controlled study.
      Optimal duration of the rehabilitation program should be determined by the best compromise between compliance and effectiveness; 2 to 4 weeks seems to be ineffective, whereas exceeding a 3-month duration is associated with poor compliance.
      • Carli F.
      • Zavorsky G.S.
      Optimizing functional exercise capacity in the elderly surgical population.
      ,
      • Dronkers J.J.
      • Lamberts H.
      • Reutelingsperger I.M.
      • et al.
      Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: A randomized controlled pilot study.
      A prehab course lasting between 6 and 8 weeks that is focused on the 3 key areas of preoperative physical exercise, nutritional care, and psychological support appears to be a good compromise between feasibility and effectiveness. Our current state of evidence in each area is lacking and will be a critical area for additional research, especially the validation of diagnostics and biomarkers to monitor effective prehab therapy.
      • Bottiger B.A.
      • Nicoara A.
      • Snyder L.D.
      • et al.
      Frailty in the end-stage lung disease or heart failure patient: Implications for the perioperative transplant clinician.

      Strategies to Ensure Extubation Within 6 Hours of Surgery (LOE: IIa/COR: B-NR)

      The origins of the fast-track paradigm began with replacing the standard use of high-dose opioids (meant to enhance hemodynamic stability) with a more balanced approach to anesthesia, using lower doses of opioids, shorter-acting hypnotics, and earlier extubation.
      • Cheng D.C.
      • Karski J.
      • Peniston C.
      • et al.
      Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.
      ,
      • Engelman R.M.
      • Rousou J.A.
      • Flack 3rd, J.E.
      • et al.
      Fast-track recovery of the coronary bypass patient.
      This approach, now almost 3 decades old, has been shown to be safe and reproducible and results in significant cost savings.
      • Cheng D.C.
      • Karski J.
      • Peniston C.
      • et al.
      Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial.
      ,
      • Cheng D.C.
      Fast-track cardiac surgery: Economic implications in postoperative care.
      • Ender J.
      • Borger M.A.
      • Scholz M.
      • et al.
      Cardiac surgery fast-track treatment in a postanesthetic care unit: Six-month results of the Leipzig fast-track concept.
      • Silbert B.S.
      • Santamaria J.D.
      • O'Brien J.L.
      • et al.
      Early extubation following coronary artery bypass surgery: A prospective randomized controlled trial. The Fast Track Cardiac Care Team.
      Earlier extubation after cardiac surgery decreases the duration of mechanical ventilation and intensive care unit length of stay, hence its adoption as a Society of Thoracic Surgeons quality of care benchmark.
      • Meade M.O.
      • Guyatt G.
      • Butler R.
      • et al.
      Trials comparing early vs late extubation following cardiovascular surgery.
      • Winkley Shroyer A.L.
      • Bakaeen F.
      • Shahian D.M.
      • et al.
      The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The driving force for improvement in cardiac surgery.
      • Wong W.T.
      • Lai V.K.
      • Chee Y.E.
      • et al.
      Fast-track cardiac care for adult cardiac surgical patients.
      Reintubation results in increased hospital mortality; therefore, it is important to stratify cardiac surgical patients to maximize the success of the fast track pathway.
      • Epstein S.K.
      • Ciubotaru R.L.
      • Wong J.B.
      Effect of failed extubation on the outcome of mechanical ventilation.
      To this purpose, scoring systems have been proposed, and simple clinical metrics such as cross-clamp time, postoperative normothermia, and inotropic use have been directly related to successful early extubation.
      • Subramaniam K.
      • DeAndrade D.S.
      • Mandell D.R.
      • et al.
      Predictors of operating room extubation in adult cardiac surgery.
      • Waseem Z.
      • Lindner J.
      • Sgouropoulou S.
      • et al.
      Independent risk factors for fast-track failure using a predefined fast-track protocol in preselected cardiac surgery patients.
      • Leslie K.
      • Sessler D.I.
      The implications of hypothermia for early tracheal extubation following cardiac surgery.
      Various anesthetic and analgesic techniques have been used effectively, the unifying principle being the optimization of patients’ physiology and pharmacology to facilitate extubation.
      • Borracci R.A.
      • Ochoa G.
      • Ingino C.A.
      • et al.
      Routine operation theatre extubation after cardiac surgery in the elderly.
      • Landoni G.
      • Lomivorotov V.V.
      • Nigro Neto C.
      • et al.
      Volatile anesthetics versus total intravenous anesthesia for cardiac surgery.
      • Totonchi Z.
      • Azarfarin R.
      • Jafari L.
      • et al.
      Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: A randomized clinical trial.
      • Zakhary W.Z.A.
      • Turton E.W.
      • Flo Forner A.
      • et al.
      A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients.
      The use of a postanesthesia or high-dependency unit as an alternative to a traditional intensive care unit for low-risk patients has been described and may encourage early extubation in a safe and cost-effective manner.
      • Ender J.
      • Borger M.A.
      • Scholz M.
      • et al.
      Cardiac surgery fast-track treatment in a postanesthetic care unit: Six-month results of the Leipzig fast-track concept.
      ,
      • Probst S.
      • Cech C.
      • Haentschel D.
      • et al.
      A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: A prospective randomized trial.
      Specific details will depend on each institution's local environment; however, the first step to successful implementation always will be the creation of a multidisciplinary team to develop and apply a site-specific perioperative protocol.
      • Richey M.
      • Mann A.
      • He J.
      • et al.
      Implementation of an early extubation protocol in cardiac surgical patients decreased ventilator time but not intensive care unit or hospital length of stay.
      There has been recent enthusiasm in pursuing the shortest extubation times possible, including in the operating room.
      • Grant M.C.
      • Isada T.
      • Ruzankin P.
      • et al.
      Results from an enhanced recovery program for cardiac surgery [E-pub ahead of print].
      ,
      • Borracci R.A.
      • Ochoa G.
      • Ingino C.A.
      • et al.
      Routine operation theatre extubation after cardiac surgery in the elderly.
      ,
      • Totonchi Z.
      • Azarfarin R.
      • Jafari L.
      • et al.
      Feasibility of on-table extubation after cardiac surgery with cardiopulmonary bypass: A randomized clinical trial.
      Grant et al. showed a nearly full-day reduction in hospital length of stay when operating room extubation was followed using an enhanced recovery protocol.
      • Grant M.C.
      • Isada T.
      • Ruzankin P.
      • et al.
      Results from an enhanced recovery program for cardiac surgery [E-pub ahead of print].
      Future studies will need to distinguish between the benefits derived from optimizing a patient for extubation as opposed to those attributed to a predetermined time and location to perform the task. Unit resources may need to be evaluated to facilitate extubation at night, but a recent large retrospective analysis indicates that this practice is safe.
      • Gershengorn H.B.
      • Wunsch H.
      • Hua M.
      • et al.
      Association of overnight extubation with outcomes after cardiac surgery in the intensive care unit.
      Additional potential benefits, such as reduced delirium or improved patient/family satisfaction, also should be investigated.

      Preoperative Correction of Nutritional Deficiency When Feasible (LOE: IIa/COR: C-LD)

      Optimizing perioperative nutrition has the potential to improve a wide range of patient outcomes (eg, less surgical site infection, improved wound healing, reduced mechanical ventilation times, shorter intensive care unit stay, less hospital readmission, and lower mortality).
      • Rahman A.
      • Hasan R.M.
      • Agarwala R.
      • et al.
      Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the “modified NUTRIC” nutritional risk assessment tool.
      • Stoppe C.
      • Goetzenich A.
      • Whitman G.
      • et al.
      Role of nutrition support in adult cardiac surgery: A consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery.
      • Wei X.
      • Day A.G.
      • Ouellette-Kuntz H.
      • et al.
      The association between nutritional adequacy and long-term outcomes in critically ill patients requiring prolonged mechanical ventilation: A multicenter cohort study.
      At the moment, the evidence quantifying the benefits of nutritional support in cardiac surgical patients is promising but limited.
      • Manners J.M.
      Nutrition after cardiac surgery.
      • Preiser J.C.
      • van Zanten A.R.
      • Berger M.M.
      • et al.
      Metabolic and nutritional support of critically ill patients: Consensus and controversies.
      • Singer P.
      • Hiesmayr M.
      • Biolo G.
      • et al.
      Pragmatic approach to nutrition in the ICU: Expert opinion regarding which calorie protein target.
      Preoperative malnutrition is associated with an increased proinflammatory, immune-suppressive response to surgical stress. The resultant increased risk for end-organ dysfunction can lead to higher morbidity and mortality in cardiac surgery, making it an attractive target for patient optimization.
      • Chermesh I.
      • Hajos J.
      • Mashiach T.
      • et al.
      Malnutrition in cardiac surgery: Food for thought.
      ,
      • Sanchez J.A.
      • Sanchez L.L.
      • Dudrick S.J.
      Nutritional considerations in adult cardiothoracic surgical patients.
      Several nutrition screening tools have been evaluated for use in general intensive care unit patients, but similar research in cardiac surgery patients is lacking.
      • Detsky A.S.
      • Baker J.P.
      • O'Rourke K.
      • et al.
      Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery.
      ,
      • Kondrup J.
      • Rasmussen H.H.
      • Hamberg O.
      • et al.
      Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials.
      Patient factors, such as age; comorbidities; nutritional status (eg, cardiac cachexia); and muscle mass have an effect on the physical functioning of patients after cardiac surgery. Therefore, studies are urgently needed to assist clinicians in identifying who will benefit the most from a preoperative nutritional support strategy. Another unanswered question involves the timing and duration of nutritional correction relative to upcoming surgery. Literature in noncardiac surgical populations suggests that an effective duration of preoperative support is 4 to 14 days—a timeframe that may not be possible in many cardiac surgery patients.
      • Jie B.
      • Jiang Z.M.
      • Nolan M.T.
      • et al.
      Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk.
      Additional research is required in cardiac surgical patients, particularly to determine the risk-benefit balance if surgery would be delayed to correct nutritional deficiencies. The ERAS Cardiac recommendations are directed toward preoperative support but do not address the postoperative nutritional needs of cardiac surgical patients who regularly experience iatrogenic malnutrition, with some receiving only 20% to 30% of their energy and protein needs.
      • Rahman A.
      • Hasan R.M.
      • Agarwala R.
      • et al.
      Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the “modified NUTRIC” nutritional risk assessment tool.
      ,
      • Hill A.
      • Nesterova E.
      • Lomivorotov V.
      • et al.
      Current evidence about nutrition support in cardiac surgery patients-what do we know?.
      This is a particularly relevant issue in high-risk and complex patients with prolonged intensive care unit stays. Nutrition support, especially enteral nutrition (EN), often is withheld early in the postoperative phase of care because of concerns for paralytic ileus, gut ischemia/reperfusion injury, vasopressor support, or hemodynamic instability, despite guidelines suggesting only the latter is a justified reason to withhold EN.
      • Hill A.
      • Nesterova E.
      • Lomivorotov V.
      • et al.
      Current evidence about nutrition support in cardiac surgery patients-what do we know?.
      ,
      • McClave S.A.
      • Taylor B.E.
      • Martindale R.G.
      • et al.
      Guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
      To meet the nutritional needs of postoperative cardiac surgical patients, combined EN and parenteral nutrition increasingly is being viewed as a promising strategy. Preliminary evidence demonstrates its effectiveness in general intensive care unit patients, and it will now require additional study in the cardiac surgical population.
      • Heidegger C.P.
      • Berger M.M.
      • Graf S.
      • et al.
      Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: A randomised controlled clinical trial.
      • Stoppe C.
      • Whitlock R.
      • Arora R.C.
      • et al.
      Nutrition support in cardiac surgery patients: Be calm and feed on!.
      • Wischmeyer P.E.
      • Hasselmann M.
      • Kummerlen C.
      • et al.
      A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: The TOP-UP pilot trial.
      Substantial research in this area is required before a comprehensive, perioperative, effective, and evidence-based approach can be established.

      Continued Consumption of Clear Liquids Until 2 to 4 Hours Before General Anesthesia (LOE: IIb/COR: C-LD)

      Despite numerous randomized controlled trials resulting in high-grade evidence and conclusive consensus guideline language to the contrary, perioperative providers continue to subscribe to lengthy nil per os (NPO) recommendations for patients before elective surgery (ie, NPO after midnight).
      Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.
      ,
      • Brady M.
      • Kinn S.
      • Stuart P.
      Preoperative fasting for adults to prevent perioperative complications.
      In the noncardiac setting, provision of clear fluids up to 2 hours before surgery has been shown not only to be safe but also to improve patient satisfaction and potentially optimize fluid status.
      • Brady M.
      • Kinn S.
      • Stuart P.
      Preoperative fasting for adults to prevent perioperative complications.
      Data respective to cardiac surgery are lacking and include few trials devoted to the subject. Patient pathology, particularly concomitant diabetes, theoretically may contribute to increased risk of delayed gastric emptying.
      • Sabry R.
      • Hasanin A.
      • Refaat S.
      • et al.
      Evaluation of gastric residual volume in fasting diabetic patients using gastric ultrasound.
      In addition, this topic generally is unstudied in the setting of transesophageal echocardiography, which may contribute to the risk of aspiration. From a practical standpoint, cardiac surgical times can be unpredictable, and even elective schedules are dynamic, which may complicate the implementation of shorter NPO timelines.

      Preoperative Oral Carbohydrate Loading May Be Considered Before Surgery (LOE: IIb/COR: C-LD)

      Regardless of one's willingness to liberate from traditional NPO guidelines, the provision of a carbohydrate (CHO) load in cardiac surgery is an ERAS Cardiac recommendation that warrants further discussion. There are convincing data to support the oral administration of 25 to 50 g of CHO before noncardiac surgery as a means to reduce insulin resistance and perioperative hyperglycemia, hasten the return of gastrointestinal function, and improve patient satisfaction.
      • Awad S.
      • Varadhan K.K.
      • Ljungqvist O.
      • et al.
      A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery.
      • Bilku D.K.
      • Dennison A.R.
      • Hall T.C.
      • et al.
      Role of preoperative carbohydrate loading: A systematic review.
      • Ljungqvist O.
      Modulating postoperative insulin resistance by preoperative carbohydrate loading.
      • Smith M.D.
      • McCall J.
      • Plank L.
      • et al.
      Preoperative carbohydrate treatment for enhancing recovery after elective surgery.
      Whether these benefits are translated to the cardiac surgery setting remains a topic of debate as a result of conflicting studies. Although the practice appears to be safe and provides some hemodynamic benefit, it is unclear whether it affects perioperative insulin requirements.
      • Breuer J.P.
      • von Dossow V.
      • von Heymann C.
      • et al.
      Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery.
      • Feguri G.R.
      • de Lima P.R.L.
      • de Cerqueira Borges D.
      • et al.
      Preoperative carbohydrate load and intraoperatively infused omega-3 polyunsaturated fatty acids positively impact nosocomial morbidity after coronary artery bypass grafting: A double-blind controlled randomized trial.
      • Jarvela K.
      • Maaranen P.
      • Sisto T.
      Pre-operative oral carbohydrate treatment before coronary artery bypass surgery.
      Given the importance of tight glycemic control in the cardiac surgery setting, CHO administration, particularly in the diabetic population, stands to directly affect other important aspects of perioperative care (ie, insulin management). At least 2 studies have reported on their experience, with one revealing no increased incidence of perioperative hyperglycemia when incorporating an oral CHO load as part of a comprehensive perioperative program.
      • Li M.
      • Zhang J.
      • Gan T.J.
      • et al.
      Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: A randomized clinical trial.
      ,
      • Williams J.B.
      • McConnell G.
      • Allender J.E.
      • et al.
      One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.
      A proper prospective trial outlining the risks and benefits of an oral CHO drink (or any other preoperative beverage) is unlikely to be forthcoming. The challenges of investigating a low-incidence adverse event (aspiration) with an ill-defined beneficial outcome (bowel function) are just a few obstacles. In the absence of such a trial, institutions are likely to assess the individual risk/benefit profile and tailor their approach based on accumulated retrospective data and local resources/workflow.

      Conclusion

      The ERAS Cardiac published recommendations are an important first of many important steps toward a comprehensive perioperative strategy to optimize the care of cardiac surgical patients, “from home to home.” Many of the recommendations have sufficient preliminary or retrospective evidence to warrant inclusion but require additional research to properly determine the true nature of their purported benefits. Although challenging, a large prospective multicenter trial measuring the effect of implementation of an ERAS Cardiac program would be ideal, although the complexity of such an undertaking will be a barrier. Continued development of our knowledge in this area will require an international multidisciplinary collaboration, from individuals and organizations alike. Finally, in our rush to embrace the principles of enhanced recovery, we must not forget its purpose—the patient's surgical experience. Involvement of patient advocates in program design and implementation and the inclusion of patient-centered outcome measures will ensure that our pathways lead in the right direction. There is much work be done.
      A.J. Gregory is a non-remunerated executive board member of the ERAS Cardiac Society, and A. Gregory and M. Grant are unpaid executive board members of the ERAS Cardiac Society. All other authors (except M. Meniere) are members of either the advisory board or subject matter experts for the ERAS Cardiac Society. M.W. Manning is on the Advisory Board for Edwards Life Sciences, Irvine, CA, and is a consultant/author for Up-to-date, (Waltham, Massachusetts, United States) Dr. J.Ender is a consultant for Phillips, Andover, MA. M. Sanders has received grants from Medtronic, Minneapolis, MN; Edwards Lifesciences; Maimed, Wien, Austria; BTG, London, UK; Getinge Group, Gothenburg, Sweden; Fisher & Paykel, East Tamaki, New Zealand; Grünenthal, Aachen, Germany; and Massimo, Irvine, CA. A. Zarbock has received grants from Baxter; Fresenius, Bad Homburg, Germany; Astute Medical, San Diego, CA; and the German Research Foundation, Bonn Germany; and lecture fees from BiomMerieux, Marcy-l'Étoile, France; Astute Medical; Braun, Kronberg, Germany; Fresenius; Baxter; Ratiopharm, Ulm, Germany; and Amomed. K- Ghadimmi has received research funding from the National Institutes of Health ( T32GM008600 ) and is a consultant for UpToDate. P.A. Patel is a speaker for Edwards Lifesciences. A. Denault is a speaker for CAE Healthcare, Saint-Laurent, Quebec, Canada; Masimo; and Edwards Lifesciences. A. Shaw is a consultant for Edwards Lifesciences. J.H. Levy is on the scientific advisory committees for Boehringer Ingelheim, Ingelheim am Rhein, Germany; CSL Behring, King of Prussia, PA; Instrumentation Labs, Bedford, MA; Merck, Kenilworth, NJ; and Octapharma, Hazelwood, MO.

      Conflict of Interest

      The authors do not have any conflicts of interest to declare.

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      Linked Article

      • Universally Implemented Enhanced Recovery After Cardiac Surgery
        Journal of Cardiothoracic and Vascular AnesthesiaVol. 35Issue 12
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          We read with interest the editorial by Gregory et al.,1 which commented on the recent guideline by Engelman et al.2 We wish to add our comments on the practicalities of these guidelines; the barriers to their implementation; and future steps regarding how best to define, practice, and study enhanced recovery in the context of cardiac surgery.
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