HISTORY
The concept was pioneered in the late 1990s
by Kehlet,[3] a Danish surgeon. Kehlet aimed to
challenge traditional perioperative care practices,
which often involved prolonged fasting, extensive
bowel preparations, and delayed mobilization. Kehlet's
initial work focused on colorectal surgery, where
he demonstrated that a multidisciplinary approach
could significantly reduce postoperative complications
and hospital stays. This approach integrated various
evidence-based practices, including optimal pain
management, early mobilization, and nutritional
support, into a cohesive protocol. Since then, the
principles of ERAS have been adapted to all surgical
specialties, including gynecology, orthopedics, urology,
and, most recently, cardiac surgery.
The genesis of the ERAS Society can be traced back to the formation of the ERAS Study Group, initiated by pioneering surgeons Fearon et al.[4] in 2001. Officially becoming a nonprofit medical society in 2010, the ERAS Society has grown to encompass a range of subspecialties. It advocates for the implementation of uniform best practices throughout the perioperative process, underscores the significance of empirical self-assessment, and fosters enhancements in patient treatment. Protocols of ERAS were developed to address the specific needs of cardiac surgery patients. These protocols incorporated key principles while considering the unique aspects of cardiac procedures. In 2017, a pioneering collaboration among cardiac surgeons, anesthesiologists, and intensivists marked the formation of the Society for Enhanced Recovery After Cardiac Surgery (ERAS Cardiac). In 2019, they took a significant step forward by releasing their inaugural guidelines. This publication offered a comprehensive review of existing literature and set forth evidence-based recommendations to optimize patient care in cardiac surgery.[5]
GUIDELINES
Initiated with a seminal consensus document
for colonic procedures in 2005, the ERAS
Society has broadened its impact by adapting the
colorectal surgery protocol to a range of surgical
fields, achieving noteworthy outcomes. Since
its inception, the ERAS Society has released 20
guidelines covering a wide spectrum of surgeries and
perioperative care practices.[6] The groundbreaking 2019 publication introduced the first expert consensus
on enhanced recovery protocols for cardiac surgery,
outlining 22 care bundles grounded in evidence.[5]
This pioneering work emphasizes shifting towards a
standardized, patient-focused care model, underscored
by diligent auditing and benchmarking. The guidelines
were formulated based on a comprehensive evaluation
of various study types, with evidence quality
appraised to establish consensus recommendations,
receiving endorsement from the ERAS Society. With
evolving clinical insights and the identification of
new perioperative approaches, there has been a drive
to update these protocols. An international panel of
multidisciplinary experts convened to expand upon
the ERAS Cardiac framework, rigorously examining
the literature to refine clinical practice guidelines
for cardiac surgery. Following the addition of many
new publications and evidence on various topics
related to cardiac surgery, an updated consensus
statement by the ERAS Society was published in
2024.[7] The new document has a broader focus
on integrating interdisciplinary care and enhancing
recovery through various strategies, covers new
advancements and updates since the 2019 guidelines,
and incorporates new clinical trials and research,
including recent findings on patient engagement
tools, prehabilitation, and multimodal analgesia.
It emphasizes the importance of interdisciplinary
collaboration and continuous improvement by
providing updated strategies for integrating protocols
in diverse healthcare environments. The classes of
recommendation and levels of evidence are briefly
summarized in Table 1a and b. All tools for education,
information, turnkey order sets, and publications
are listed in the ERAS Cardiac Society homepage
(www.erascardiac.org).
Table 1b. Summary of modification/additions in updated consensus statement (2024)
INTERDISCIPLINARY COLLABORATION
AND TEAMWORK
The assembly of the multidisciplinary team is
pivotal to the ERAS program's success, with
composition tailored to available hospital resources.
Key stakeholders include nursing staff, surgeons,
anesthesiologists, intensivists, pharmacists,
perfusionists, advanced practice providers, registered
dietitians, respiratory and physical therapists, case
managers, and cardiac rehabilitation specialists.
Central to this team's effectiveness is a unified
commitment to transformative care principles,
necessitating a collaborative approach to cultural
adaptation, education, and seamless coordination of
patient care, ensuring each member contributes to the
comprehensive, patient-centered recovery pathway.[8] Involving patients and their families in the recovery
process can improve compliance and satisfaction.
Providing clear information and support can empower
patients to take an active role in their recovery.
KEY COMPONENTS OF ERAS CARDIAC
PROTOCOLS
The ERAS Cardiac program outlines a
structured approach to enhance recovery after cardiac surgery and encompasses the following
principles: (i) identification of key care bundles
with potential recovery impact, (ii) understanding postsurgical event or complication rates within these
bundles, (iii) formulating strategies to mitigate these
issues, (iv) establishing uniform care protocols, and (v) gathering and analyzing data to assess
intervention outcomes.[9] Our institutional protocol
is demonstrated in Table 2. These protocols are
structured into three main phases: preoperative,
intraoperative, and postoperative.
Table 2. Enhanced Recovery After Cardiac Surgery brief protocol
PREOPERATIVE PHASE
Patient education and prehabilitation
Educating patients about the surgical procedure,
expected outcomes, and recovery process is crucial.
A comprehensive prehabilitation program includes
physical conditioning, nutritional and glucose
management, advice on quitting smoking and
moderating alcohol intake, and psychosocial support.
Additionally, patients receive guidance on setting
realistic pain management expectations, focusing on
opioid-sparing techniques, encouraging early and
regular postoperative walking, and adhering to strict
discharge criteria.[10] The prehabilitation program
begins with an interdisciplinary consultation two to
three weeks prior to surgery. During this session,
patients undergo a comprehensive evaluation of their
physical condition, including frailty and functional
capacity, to determine their readiness and willingness
to engage in the program. A key focus is placed on
physiotherapeutic exercises, urging patients to increase
daily physical activities and enhance their nutritional
status before surgery to optimize their overall readiness
and outcomes.[11,12]
Nutritional optimization
Perioperative malnutrition exacerbates metabolic
issues caused by surgical stress, leading to
slower wound healing, heightened infection risk,
prolonged hospital stays, and increased mortality.
Addressing this, the Perioperative Quality Initiative
and the American Society for Enhanced Recovery
recommended preoperative nutritional screening for
all major surgery patients in 2018.[13] Those at risk
should receive oral nutritional supplements at least
seven days before surgery to mitigate malnutrition's
adverse effects and enhance surgical outcomes.[14,15]
Identification and treatment of preoperative
anemia and a comprehensive patient blood
management strategy
Identifying and managing preoperative anemia,
prevalent in up to 40% of surgical patients, is
critical for minimizing postoperative complications.
Addressing anemia before surgery, primarily through
the assessment of iron levels, occult blood loss,
and other conditions, is vital to enhance patients'
physiological resilience and reduce the necessity for blood transfusions. Implementing standardized
transfusion protocols within an ERAS Cardiac
framework, based on specific triggers including
intraoperative hematocrit levels and oxygen delivery
metrics, alongside auditing transfusion practices,
ensures adherence to best practices and improves
patient outcomes.
The benefit of a multidisciplinary patient blood management (PBM) care pathway in cardiac surgery has been established in the literature and is reflected in the numerous guidelines published by major societies. However, despite the importance of PBM, implementation remains variable across institutions. Patient blood management protocols play an important role in ERAS Cardiac by minimizing blood loss, reducing the need for transfusions, and improving overall patient outcomes. By implementing strategies such as preoperative anemia management, meticulous surgical techniques, and the use of antifibrinolytic agents, PBM protocols help maintain optimal hemoglobin levels, reduce the risk of complications, and shorten hospital stays. These measures not only enhance patient safety and recovery but also contribute to more efficient use of healthcare resources, ultimately leading to better long-term health for cardiac surgery patients.[16-18]
Preoperative fasting and carbohydrate loading
The American Society of Anesthesiology's
1999 revision of fasting guidelines encourages
preoperative carbohydrate loading, allowing clear
liquids up to 2 h before surgery to enhance patient
satisfaction and clinical outcomes.[19] This approach
reduces glucose variability and postoperative
insulin resistance.[20] The ERAS Cardiac guidelines
recommend 800 mL of a 12.5% carbohydrate clear
drink the night before and 400 mL of the same fluid
2 h prior to surgery, except for patients with severe
diabetes due to different insulin dynamics.[21]
Premedication
For premedication, avoiding benzodiazepines and
other long-acting drugs is advised due to their
association with increased delirium risk. Pregabalin at
a dose of 75 mg is effective in reducing postoperative
morphine requirements and lowering the chance of
chronic postoperative pain with fewer side effects
such as somnolence and dizziness compared to
gabapentin.[22]
Multimodal analgesia to mitigate intraoperative
and postoperative opioid use
Detailed monitorization
Goal-directed fluid therapy
Minimally invasive techniques
Reducing surgical site infections
Minimally invasive extracorporeal circulation
POSTOPERATIVE PHASE
Postoperative Nausea and Vomiting
Pain control
Normothermia
Early extubation
Avoiding delays in removal of tubes, drains, and
lines
Postoperative atrial fibrillation
Screening and prevention of perioperative
delirium
AUDIT
Implementation
Implementing protocols presents several
challenges, including variability in protocol
adherence, financial resource constraints, and the
need for extensive staff training. This can require
significant initial investment in training, resources,
and infrastructure, which can be a deterrent for
many institutions, particularly those with limited
budgets. Communication gaps can impede the
integration of protocols. Integrating new protocols
into existing workflows can be challenging and may
require significant adjustments to daily routines
and procedures. The diverse health status of
patients undergoing cardiac surgery can complicate
standardization.[42,43]
Clinical evidence and outcomes
Williams et al.[44] conducted a study comparing
patients managed with pre-ERAS Cardiac protocols
(n=489) and post-ERAS Cardiac protocols (n=443).
They found that the median postoperative length of
stay decreased from 7 to 6 days (p<0.01) and total
ICU hours reduced from a mean of 43 to 28 h (p<0.01).
The incidence of gastrointestinal complications
dropped from 6.8 to 3.6% (p<0.05). Opioid use
decreased by an average of 8±1.2 mg of morphine
equivalents per patient in the first 24 h postoperatively
(p<0.01). Additionally, the rates of reintubation and
ICU readmission were reduced by 1.2% and 1.5%,
respectively. Patient satisfaction increased from 86.3%
with pre-ERAS Cardiac protocols to 91.8% with post-
ERAS Cardiac protocols, with improvements across
all measured indices, including patient focus, culture,
and engagement.
In another propensity-matched analysis (n=76),
patients managed based on ERAS Cardiac protocols
experienced significantly shorter median ventilation
times (3.5 vs. 5.3 h, p=0.01), median ICU stays (28 vs.
48 h, p=0.005), and median hospital stays (5 vs. 6 days,
p=0.03).[45]
A recent meta-analysis covering 13 single-center
randomized controlled trials (a total of 1,704 patients;
850 managed with ERAS Cardiac-like protocols and
854 in the standard care group) found no significant
difference in in-hospital mortality between the ERAS
Cardiac and standard treatment groups.[46] However,
ERAS Cardiac was associated with reduced ICU stays
(standardized mean difference [SMD]=-0.57, p<0.01),
shorter hospital stays (SMD= -0.23, p<0.01), and lower
overall complication rates compared to the standard
protocol (relative risk [RR]=0.60, p<0.01), primarily
due to a reduction in stroke incidence (RR=0.29
[0.13; 0.62], p<0.01).
Another meta-analysis evaluating 15 studies
(a total of 5,059 patients; 1,706 in the study group
and 3,353 in the control group) demonstrated that
improved recovery protocols in cardiac surgery
decreased perioperative complications (RR=0.73,
95% confidence interval [CI]: 0.52-0.98) and reduced hospital readmissions within 30 days after surgery
(RR=0.51, 95% CI: 0.31-0.86).[47] Differences in
extubation time, hospital stay, and ICU length of stay
were less pronounced but still favored the ERAS
Cardiac group.
In a systematic review, Zhang et al.[48] evaluated
one randomized controlled trial, one quasiexperiment,
and seven retrospective/prospective
studies. They found significant improvements in
hospital and ICU lengths of stay, as well as reductions
in postoperative opioid consumption, without an
increase in postoperative complications.
A meta-analysis focused on valve surgery
identified 5,142 patients across 14 studies
(2,501 in ERAS Cardiac groups and 2,641 in
control groups).[49] Seven studies exclusively included
patients who underwent heart valve surgery. Despite
high heterogeneity among the included protocols
regarding key actions and measured outcomes, all
studies indicated that ERAS Cardiac pathways can
be safely adopted in cardiac surgery, often resulting
in shorter mechanical ventilation times, reduced
postoperative opioid use, and decreased ICU and
hospital stays.
Our group studied 445 consecutive frail patients
undergoing open-heart surgery managed by the
ERAS Cardiac protocol versus 445 propensity
score-matched patients.[50] We observed significantly
better outcomes in early extubation, red blood
cell transfusion, need for reintubation, ICU
stay/readmission, and hospital stay/readmission in the
study group. The EuroQol-visual analog scale score
significantly improved in the ERAS Cardiac group
compared to preoperative levels, with a 35% reduction
in costs.
Despite these positive findings, many publications
lack scientific rigor, often relying on cohort studies
rather than clinical trials, focusing on incremental
effectiveness, or involving small, highly select patient
populations with limited external validity. While
ERAS Cardiac protocols show potential advantages,
further research into its components and their
interactions is needed. More research is needed to
optimize protocols for different cardiac procedures
and patient populations. While short-term benefits
are well-documented, there is a need for studies
focusing on long-term outcomes, including quality
of life, functional recovery, and healthcare costs.
Exploring the integration of new technologies, such
as enhanced monitoring systems and personalized
medicine approaches, can further improve protocols
and patient outcomes.
Challenges and limitations
Future directions and innovations
Data Sharing Statement: The data that support the findings
of this study are available from the corresponding author upon
reasonable request.
Author Contributions: All authors contributed equally to
the article.
Conflict of Interest: The authors declared no conflicts of
interest with respect to the authorship and/or publication of this
article.
Funding: The authors received no financial support for the
research and/or authorship of this article.
The intraoperative phase aims to modernize
surgical practices by reducing the use of nasogastric tubes, drains, and catheters. Care is also taken to ensure
a proper fluid and hemodynamic balance, as well as
employing minimally invasive techniques, along with
using opioid-sparing multimodal analgesia. Emphasis
is also placed on appropriate use of antimicrobials and
nausea prophylaxis.[23] Key goals include meticulous
management of fluids and hemodynamics during
cardiopulmonary bypass to prevent fluid overload and
organ dysfunction, marking a significant departure
from traditional approaches.
Effective pain management after cardiac surgery is
vital to prevent complications such as hemodynamic
instability, postoperative delirium, prolonged
intubation, chronic pain, and the risk of opioid
dependency. To counteract these issues, multimodal
analgesia has become a cornerstone of ERAS
Cardiac protocols. This approach combines various
analgesic medications and anesthetic techniques
to address pain by targeting both peripheral and
central receptors, reducing the need for opioids
while maintaining effective pain relief. Common
nonopioid analgesics include acetaminophen,
ketamine, dexmedetomidine, gabapentin, and
pregabalin. Additionally, neuraxial and regional
anesthesia methods are increasingly used within
these frameworks. The unique aspect of multimodal
analgesia is educating patients before surgery about
pain management expectations, understanding the
multimodal strategy, and being aware of the risks
associated with opioids.[24,25] The ERAS Cardiac
program emphasizes advanced pain management
techniques and specific intraoperative anesthesia
and physiological management goals. This includes
lung-protective ventilation strategies using low
tidal volumes and positive end-expiratory pressure,
alongside lung recruitment maneuvers. Blood
conservation techniques such as cell-saving and
viscoelastic testing are also integrated to minimize
blood loss and the need for transfusions, aligning
with the comprehensive strategy to optimize patient
outcomes during cardiac surgery.[26]
Transesophageal echocardiography is essential
in cardiac surgery for monitoring. It provides a
thorough view of the heart"s structure and function,
including the aorta, cardiac performance, volume
status, valve structure/function, and shunt detection.
Transesophageal echocardiography is less invasive
compared to pulmonary artery catheterization and offers more accurate and reliable information,
making it crucial for intraoperative management
and decision-making in most cardiac surgeries.[27]
Advanced hemodynamic monitoring systems, such
as pulse contour analysis and esophageal Doppler
monitoring, allow real-time assessment of a patient's
cardiovascular status during and after surgery.
These technologies provide detailed insights into
fluid status and cardiac function, enabling precise
management. Additionally, wearable technologies
such as continuous glucose monitors and activity
trackers offer valuable data on a patient's physiological
state and activity levels.
Cardiac surgery's complexity requires careful fluid
management to accommodate changes in myocardial
function, significant fluid shifts, and vascular
endothelium stress. Precise fluid administration
is vital to avoid overload and ensure adequate
perfusion. Goal-directed fluid therapy optimizes
fluid management by using dynamic parameters to
guide fluid administration.[28]
Utilizing minimally invasive cardiac surgery
(MICS) techniques is crucial to reducing patient
trauma and speeding up recovery times. These
methods can result in faster recovery, less pain, and
decreased infection rates. Research has demonstrated
that MICS, particularly when combined with ERAS
Cardiac protocols, is extremely effective. Integrating
MICS with ERAS Cardiac may further enhance the
beneficial outcomes.[29,30]
To decrease the incidence of surgical site infections,
administering antibiotics intravenously 30 to 60 min
before the incision is effective. Moreover, applying
antiseptic solutions to the skin can be beneficial.
Continuing antibiotic therapy for 48 h after surgery has
been shown to significantly reduce the risk of sternal
infections.[23]
Modern cardiac surgery combines advancements
in surgical methods and cardiopulmonary bypass
technology to reduce the invasiveness of procedures,
specifically for high-risk, elderly patients, who often
have multiple comorbidities. This approach reduces
the detrimental effects of cardiopulmonary bypass,
which include blood contact with artificial surfaces,
activation of the coagulation system, hemodilution, and hypoperfusion leading to microcirculatory
disturbances. The concept of more "physiological"
intraoperative perfusion has evolved to mitigate these
surgical harms, with minimally invasive extracorporeal
circulation being a central component.[31,32]
Maintaining the strategies established during
the pre- and intraoperative phases is vital in the
postoperative period. Key goals include reducing
opioid use, ensuring fluid balance, encouraging early
mobility, feeding, and promptly removing catheters
and drains.
Postoperative nausea and vomiting can
significantly affect patient satisfaction. Major risk
factors include the use of perioperative opioids,
being a nonsmoker, female sex, and a history of
motion sickness or postoperative nausea. Treatment
options include 5-HT3 antagonists, dexamethasone,
scopolamine, perphenazine, diphenhydramine,
propofol, droperidol, neurokinin-1 antagonists, and
acupuncture.[33]
The ERAS Cardiac programs incorporate
regional pain blocks, local analgesics, such as
ropivacaine injections at surgical sites, alternative
pain medications, and judicious use of opioids in
the postoperative phase, demonstrating promising
results.[34]
Hypothermia, defined as a core body temperature
below 36°C, is associated with higher risks of
postoperative complications, including arrhythmias,
surgical site infections, coagulation disorders, and
mortality. Anesthetics used in cardiac surgery can
disrupt body temperature regulation by causing
vasodilation, impacting the hypothalamus, and
decreasing sympathetic nervous activity. It is essential
to rewarm patients after cardiopulmonary bypass and
maintain warmth in the intensive care unit (ICU) using
methods such as forced-air warming and warming
blankets.[35]
Safely achieving early extubation (<6 h after the
operation) can reduce ICU and hospital stays, facilitate
earlier oral feeding and ambulation, and improve
patient satisfaction. The ERAS Cardiac protocols
emphasize minimizing intraoperative opioids and
using shorter-acting anesthetics, making early extubation feasible for many patients.[36] Early and
frequent mobilization are critical components of these
protocols and should be communicated to patients
before hospital admission to ensure compliance.
Early postoperative movement helps reduce pain,
fatigue, deep vein thrombosis, cognitive dysfunction,
and anxiety. Patients begin their first postoperative
physiotherapy session two to three hours after surgery,
which includes breathing exercises/active mobilization
while seated and upright. These exercises continue
until the third to fourth postoperative day, with pain
medication managed according to a standardized
protocol. As a result of intensive physiotherapy,
patients are typically discharged by the fourth or fifth
postoperative day.
Removing tubes, drains, and lines as soon as they
are no longer necessary promotes early mobilization,
reduces patient discomfort, and minimizes the risk of
associated infections.[37]
Postoperative atrial fibrillation is a common
complication after cardiac surgery, associated with
increased adverse outcomes. Preoperatively, it is
recommended to screen patients for paroxysmal
or chronic atrial fibrillation and start appropriate
treatments based on individual risk assessments for
postoperative atrial fibrillation. This may include
administering beta-blockers or amiodarone, tailored
to the patient's specific risk profile. Intraoperatively,
surgical procedures such as posterior pericardiotomy
should be considered for select patients.
Postoperatively, it is crucial to focus on electrolyte
normalization, strategies for rate or rhythm control,
and anticoagulation management.[38]
To combat perioperative delirium, a notable
complication after cardiac surgery, routine screening
with standardized tools is essential for early
identification and management, potentially reducing
subsequent morbidity. Essential strategies include
encouraging perioperative ambulation, ensuring
access to vision and hearing aids, fostering family
interactions, maintaining regular sleep/wake cycles,
and frequent patient reorientation. Additionally,
addressing pain using multimodal analgesics
is crucial, as pain significantly contributes to the
development of postoperative delirium.[39,40]
Given the complexity of the care process,
continuous auditing of patient outcomes and care
procedures helps the team maintain a comprehensive
perspective. While most healthcare facilities use
electronic medical records, creating detailed reports
to capture essential data points can be challenging.
Real-time data capturing allows stakeholders to
review and act on current information. Adjustments
to care should be made if compliance or outcomes fall
short of goals. Measuring outcomes and compliance
together are basics for identifying challenges and
improvement opportunities.[41]
Implementing the ERAS Cardiac framework
goes beyond merely adopting new protocols and
requires a fundamental shift in healthcare culture
towards patient-centered care, enhancing both the
speed and completeness of recovery processes.
The initiative's success depends on appointing
a dedicated coordinator to oversee educational
programs, troubleshoot issues, and gather data. It
also involves identifying and leveraging the expertise
of specialty champions who may have varying
practices and preferences. Achieving consensus on
evidence-based standardization, while respecting
individual preferences is crucial. This effort
includes reviewing guidelines and the literature and
consulting with external experts to build agreement
among stakeholders. Efficiency gains are achieved
through the electronic standardization of order sets.
Tailoring adjustments to fit specific health system
needs and exploring grant funding opportunities
for program components are vital for successful
implementation.
The adoption of ERAS Cardiac protocols is
supported by a substantial and growing body of clinical evidence. Research has shown significant
benefits, including shorter hospital stays, reduced
complication rates, and improved patient satisfaction.
Notably, the number of publications on ERAS has
increased markedly, with more than 1,600 articles
on PubMed since 2000, half of which have been
published since 2016. Systematic reviews and metaanalyses
have synthesized findings from multiple
studies, offering comprehensive insights into the
protocols' effectiveness.
The ERAS Cardiac programs aim to enhance
patient outcomes and streamline recovery processes.
Despite these advantages, several challenges and
limitations exist. Patients undergoing cardiac
surgery often have diverse medical histories
and comorbidities. Customizing protocols
to individual needs can be complex, requiring
significant personalization, and potentially limiting
standardized approaches. Smaller or resourcelimited
healthcare facilities may face difficulties
meeting the necessary requirements, impeding
widespread adoption. Coordinating these efforts can
be challenging, particularly in environments with
fragmented communication systems. Adherence to
protocols is crucial for their success. Accurate data
collection and outcome measurement are essential for
evaluating the effectiveness of programs. Inconsistent
data reporting, lack of standardized metrics, and
challenges in tracking long-term outcomes can
hinder comprehensive program assessments. Despite
these challenges, ongoing research, continuous
program refinement, and adaptive strategies can help
mitigate limitations and enhance the overall success
of ERAS Cardiac initiatives, ultimately leading to
improved patient care and recovery.[51]
The ERAS Cardiac initiative is a dynamic
and evolving field. Emerging technologies,
personalized ERAS Cardiac protocols, long-term
follow-up studies, and broader application
across cardiac procedures are critical for future
development. By focusing on evidence-based
practices, interdisciplinary collaboration, and
patient engagement, ERAS Cardiac protocols have
the potential to revolutionize cardiac surgery and
improve outcomes for patients worldwide. Ongoing
research, continuous improvement, and global
dissemination are essential to realizing the full
benefits of ERAS Cardiac.