Role of cardiac anesthesiologists in intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) protocol - A retrospective single center study analyzing preliminary result of yearlong ERACS protocol implementation

Published:November 10, 2022DOI:



      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.

      ERACS protocol

      Patients that were identified by cardiac anesthesiologists and cardiac surgeons as suitable candidate for ERACS were managed according to the ERACS protocol.


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