Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid popularity
after multiple studies have shown promising results of enhanced recovery after surgery
(ERAS) in other surgical fields e.g colorectal, orthopedic, thoracic etc. Cardiac
surgery has several unique challenges including sternotomy, cardiopulmonary bypass
(CPB) and associated coagulopathy, blood transfusion and postoperative intensive care
requirement. Nonetheless, selective cardiac surgical patients still can benefit from
ERACS. Guidelines for perioperative care in cardiac surgery, previously published
by the Enhanced Recovery After Surgery Society, are heavily weighted in the pre- and
post-operative management without much focus on the intraoperative care provided by
anesthesiologists. To address this gap, and to explore anesthesiology's contribution
to achieve ERACS, our cardiac anesthesiology division in collaboration with cardiac
surgery introduced ERACS protocol in our institution in February 2020.
Cardiac anesthesiology division in collaboration with cardiac surgery introduced ERACS
protocol consisting of multimodal opioid sparing analgesia including introduction
of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade
and administration of antiemetics in our institution in February 2020. We have conducted
a retrospective chart review study comparing patients that have received ERACS measures
with a similar historical cohort that underwent cardiac surgery prior to initiation
of ERACS protocol. Primary outcomes of the study were to determine patients’ time
to extubation, postoperative opioid consumption, ICU length of stay and incidence
of postoperative complications e.g. postoperative nausea vomiting (PONV), bleeding,
ICU readmission, delirium.
ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative
fentanyl as well as oxycodone in first 6 hrs postoperatively), lesser mechanical ventilation
(2.5 hrs less), shorter intensive care unit (ICU) (5 hrs less) and shorter hospital
length of stay (LOS) (1 day), lesser incidence of PONV; None of the ERACS patients
required blood transfusion. We performed an anonymous survey among the anesthesiologists
and ICU providers to assess providers’ satisfaction which showed 92% survey takers
agreed that ERACS protocol should be continued for future cardiac patients and 61%
of survey takers reported superior pain control in ERACS group of patients while managing
those patients. (Supplementary Fig 2)
ERACS is achievable after careful implementation of series of measures. It is not
only fast track extubation and opioid sparing analgesia and must be implemented in
entire perioperative period beginning from preoperative clinic to postoperative rehabilitation.
Both providers as well as patients themselves are key stake holders. More randomized
prospective studies are needed to solidify the inference.
Patients that were identified by cardiac anesthesiologists and cardiac surgeons as
suitable candidate for ERACS were managed according to the ERACS protocol.