Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery. Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach aimed at providing bundled best practice interventions and therapies throughout the perioperative encounter.1Ljungqvist O. Scott M. Fearon K.C. Enhanced recovery after surgery: a review.JAMA Surg. 2017; 152: 292-298Crossref PubMed Scopus (2024) Google Scholar A central tenet of ERAS is the adoption of evidence-based protocols that have been published and serially updated across a number of surgical specialties.2Stenberg E. Dos Reis Falcão L.F. O'Kane M. et al.Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations: a 2021 update [published correction appears in World J Surg. 2022;46:752].World J Surg. 2022; 46: 729-751Crossref PubMed Scopus (0) Google Scholar, 3Nelson G. Bakkum-Gamez J. Kalogera E. et al.Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations–2019 update.Int J Gynecol Cancer. 2019; 29: 651-668Crossref PubMed Scopus (408) Google Scholar, 4Gustafsson U.O. Scott M.J. Hubner M. et al.Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018.World J Surg. 2019; 43: 659-695Crossref PubMed Scopus (1023) Google Scholar Registry-based observational studies reveal that high compliance with these protocols is shown to reduce surgical insult, promote recovery, and prevent postoperative complications, thereby improving the value of delivered care.5Stone A.B. Grant M.C. Pio Roda C. et al.Implementation costs of an Enhanced Recovery After Surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center.J Am Coll Surg. 2016; 222: 219-225Crossref PubMed Google Scholar, 6Thiele R.H. Rea K.M. Turrentine F.E. et al.Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.J Am Coll Surg. 2015; 220: 430-443Crossref PubMed Scopus (302) Google Scholar, 7ERAS Compliance GroupThe impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry.Ann Surg. 2015; 261: 1153-1159Crossref PubMed Scopus (497) Google Scholar, 8Grant M.C. Pio Roda C.M. Canner J.K. et al.The impact of anesthesia-influenced process measure compliance on length of stay: results from an Enhanced Recovery After Surgery for colorectal surgery cohort.Anesth Analg. 2019; 128: 68-74Crossref PubMed Scopus (36) Google Scholar In 2019, the ERAS Cardiac Society published their original guidance, which reviewed the literature and provided recommendations regarding care elements for patients undergoing cardiac surgery.9Engelman D.T. Ben Ali W. Williams J.B. et al.Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations.JAMA Surg. 2019; 154: 755-766Crossref PubMed Scopus (541) Google Scholar In the interim, new clinical data as well as recognition of additional potential perioperative strategies have necessitated an update. The ERAS Cardiac Society, in collaboration with the affiliated ERAS International Society, has assembled a committee of experts to develop a consensus statement to optimize care for the adult cardiac surgical patient. This consensus statement was developed following the 2019 "Recommendations from the ERAS Society for Standards for the Development of Enhanced Recovery After Surgery Guidelines" (ERAS Standards), which standardizes the formation of an expert guidance development group, literature search, analysis of the evidence, statement formation, and creation of the manuscript.10Brindle M. Nelson G. Lobo D.N. Ljungqvist O. Gustafsson U.O. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.BJS Open. 2020; 4: 157-163Crossref PubMed Scopus (94) Google Scholar The consensus statement development group, a multidisciplinary panel including cardiac surgeons, anesthesiologists, intensivists, and allied nurses, was identified based on individual expertise and experience with ERAS. In 2021, the expert group convened an initial meeting and agreed on potential care elements, derived from a combination of prior guidelines, surrogate examples from other subspecialties, and expert opinion, and divided into respective phases of perioperative care. This effort was then aligned with the expert consensus protocols from The Society of Thoracic Surgeons (STS) and underwent a formal review by the STS Workforce on Evidence Based Surgery prior to endorsement and submission for publication. Literature searches of individual topic areas were conducted with librarian assistance where necessary and included reviews, guideline documents, and clinical studies conducted on adult humans prior to December 2021, published in English, and retrievable from the PubMed, Embase, and Cochrane databases. Medical Subject Heading terms were identified for the care element or intervention, as were accompanying terms for the patient group, procedure, and outcome. Preference was given to meta-analyses, prospective randomized clinical trials, and well-designed, nonrandomized studies. In the event a care element or intervention was not reported in the setting of cardiac surgery, evidence pertaining to noncardiac surgical settings was considered, where appropriate. Most of the data outlined in this manuscript pertain to the elective cardiac surgical population, with any exceptions explicitly stated in the accompanying prose, along with a description of the individual case types (ie, coronary artery bypass grafting [CABG], valve, aortic, etc). A series of virtual and in-person meetings were conducted to present and discuss results as well as resolve any controversies regarding interpretation of the available evidence. Summary statements and accompanying text were modeled after prior ERAS guidelines. Quality of evidence was assessed, and designations were rendered based on whether further research is unlikely (high), likely (moderate), or very likely (low) to have an important impact on the statement of the effect of the intervention.10Brindle M. Nelson G. Lobo D.N. Ljungqvist O. Gustafsson U.O. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.BJS Open. 2020; 4: 157-163Crossref PubMed Scopus (94) Google Scholar A minimum of 70% committee agreement was required for consensus. Summary statements and associated quality of evidence are provided in Table 1, organized into general, preoperative, intraoperative, postoperative, and multiphase sections.Table 1Summary of Statements and Level of EvidenceStatementLevel of EvidencePatient engagement is improved through the incorporation of shared decision-making principles.LowProgram implementation and sustainment is facilitated through the establishment of a multidisciplinary team, including a dedicated coordinator, as an extension of the Heart Team.ModerateRoutine auditing and evaluation of perioperative process measure adherence and clinical outcomes is a necessary component of high-quality perioperative care.ModerateMultifaceted patient screening and risk assessment improves the informed consent process and allows for advanced perioperative planning.ModerateMulticomponent prehabilitation may be considered to optimize patients prior to nonurgent cardiac surgery.LowLimiting nil per oz status for clear liquids (>2 hours before surgery) is reasonable after assessment of potential risk factors for aspiration.LowTransesophageal echocardiography is encouraged in patients with moderate or high risk of perioperative morbidity or mortality.ModerateMechanical ventilation with lung-protective strategies is associated with improved mechanics and fewer pulmonary complications.HighThe role of mechanical ventilation during cardiopulmonary bypass is uncertain.ModeratePulmonary artery catheters use in low-risk patients or procedures incurs greater health care resource utilization without improving morbidity or mortality.ModerateCentral nervous system monitoring may provide an early indication of neurologic risk, but additional study is necessary to identify strategies to prevent and mitigate injury.ModerateStandardized risk factor assessment and prophylaxis has been shown to prevent postoperative nausea and vomiting.ModerateGoal-directed perfusion may play a role in preventing organ injury associated with cardiopulmonary bypass.LowStructured strategies to facilitate extubation within 6 hours of surgery have been shown to be safe and potentially hasten recovery after elective procedures.ModerateHighly selective intraoperative or immediate postoperative extubation may be appropriate for patients undergoing low-risk cardiac surgery.LowRoutine screening for and, where appropriate, the use of a comprehensive treatment care bundle can reduce the incidence and severity of postoperative acute kidney injury.ModerateEarly postoperative ambulation and upper extremity exercise is well tolerated and associated with hastened recovery.ModerateGoal-directed fluid and hemodynamic therapy can guide perioperative resuscitation and prevent postoperative organ injury.ModerateA multimodal approach reduces reliance on opioid-based analgesia and optimizes perioperative pain management.ModerateChest wall regional analgesia can be an effective component of a multimodal approach to perioperative pain management.ModerateBlood product utilization and associated outcomes are optimized through the implementation of a comprehensive patient blood management program.ModeratePostoperative atrial fibrillation is optimally addressed through the use of a multifaceted prevention strategy.ModerateRoutine use of a systematic delirium screening tool and nonpharmacologic strategies aid the identification and prevention of postoperative delirium.HighThe bundled application of evidence-based best practices has been shown to prevent surgical site infection.High Open table in a new tab Engagement of patients and their social network is an important component of perioperative care, both to foster education and establish realistic expectations. Although patient engagement and education are endorsed by multiple other ERAS subspecialty guidelines,2Stenberg E. Dos Reis Falcão L.F. O'Kane M. et al.Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations: a 2021 update [published correction appears in World J Surg. 2022;46:752].World J Surg. 2022; 46: 729-751Crossref PubMed Scopus (0) Google Scholar, 3Nelson G. Bakkum-Gamez J. Kalogera E. et al.Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations–2019 update.Int J Gynecol Cancer. 2019; 29: 651-668Crossref PubMed Scopus (408) Google Scholar, 4Gustafsson U.O. Scott M.J. Hubner M. et al.Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018.World J Surg. 2019; 43: 659-695Crossref PubMed Scopus (1023) Google Scholar cardiac surgery has also reinforced the principle of shared decision making, where patients and their representatives work directly with their clinicians to review the available evidence to determine the best therapeutic course of action while explicitly incorporating the patient's values and preferences into the decision-making process.11Lawton J.S. Tamis-Holland J.E. Bangalore S. et al.Writing Committee Members2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2022; 79: e21-e129Crossref PubMed Scopus (507) Google Scholar Patient engagement can be augmented through the use of digital technologies, including wearable remote monitors and interactive applications, which have been shown to improve adherence to the plan of care as well as facilitate data collection and analysis on social determinants of health and the value of familial involvement.12Cook D.J. Manning D.M. Holland D.E. et al.Patient engagement and reported outcomes in surgical recovery: effectiveness of an e-health platform.J Am Coll Surg. 2013; 217: 648-655Crossref PubMed Scopus (46) Google Scholar, 13Ocagli H. Lorenzoni G. 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Chen Q. et al.Association of shared decision-making on patient-reported health outcomes and healthcare utilization.Am J Surg. 2018; 216: 7-12Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Summary Statement: Patient engagement is improved through the incorporation of shared decision-making principles. Quality of Evidence: Low The cardiac surgery perioperative multidisciplinary team (MDT) represents an extension of the Heart Team model proposed by other guidelines, which has traditionally included representatives from cardiac surgery and cardiology working in concert to determine the ideal procedural intervention.11Lawton J.S. Tamis-Holland J.E. Bangalore S. et al.Writing Committee Members2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2022; 79: e21-e129Crossref PubMed Scopus (507) Google Scholar The MDT also includes core representatives from noncardiac surgical disciplines, such as anesthesiologists, nurses, allied health, pharmacists, and dietitians, as well as those more fundamental to cardiac surgery, including intensivists, perfusionists, and cardiac rehabilitation specialists. Multiple studies describe resistance to change and poor communication as a barrier to ERAS implementation, whereas an effective MDT that establishes clear communication among all disciplines is recognized as a facilitator for program success.27Stone A.B. Yuan C.T. 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Quality of Evidence: Moderate Preoperative risk assessment in cardiac surgery is important to determine a patient's suitability for surgery and identify areas for optimization. Table 2 provides a summary of preoperative laboratory and assessment criteria that may be considered as part of a comprehensive preoperative screening and risk assessment. The STS predicted risk of mortality and morbidity and the European Heart Surgery Risk Assessment System 2011 revision (EuroSCORE II) calculators are the 2 most widely used tools to determine in-hospital and early postoperative mortality and morbidity, and their use has been endorsed by other major guidelines.11Lawton J.S. Tamis-Holland J.E. Bangalore S. et al.Writing Committee Members2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2022; 79: e21-e129Crossref PubMed Scopus (507) Google Scholar,54Pittams A.P. Iddawela S. Zaidi S. Tyson N. Harky A. Scoring systems for risk stratification in patients undergoing cardiac surgery.J Cardiothorac Vasc Anesth. 2022; 36: 1148-1156Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,55Saxena A. Dhurandhar V. Bannon P.G. Newcomb A.E. The benefits and pitfalls of the use of risk stratification tools in cardiac surgery.Heart Lung Circ. 2016; 25: 314-318Abstract Full Text Full Text PDF PubMed Google ScholarTable 2Recommended Preoperative Risk Assessment ComponentsComponentRationaleSTS predicted risk of mortality and morbidity, EuroSCORE IIStratified in-hospital and short-term postoperative morbidity and mortality.Frailty assessmentPrefrail and frail status is associated with a marked increase in adjusted morbidity and mortality. There are several validated tools