Dr. Monish Raut covers the salient points of the first guideline for evidence-based cardiac surgical ERAS practices published in 2019. The recommendations arranged into pre-operative, intra-operative, and post-operative strategies strongly emphasise on prehabilitation of patients and the benefit of surgical site infection prevention care bundles.

The Enhanced Recovery After Surgery (ERAS) has been a well-known and beyond doubt, successful programme in multiple surgical specialities. The protocol is an evidence-based pathway, initially started in the colorectal surgical field in 1990s. Later, it was utilised and practiced in multiple other surgical specialities. Such an evidence-based protocol was lacking in cardiac surgery. Hence, ERAS Cardiac Society was formed in 2017 to improve perioperative patient management. The team constituted members from multidisciplinary areas – cardiac surgeons, cardiac anaesthesiologists, and cardiac intensivists. This is the first guideline for evidence-based cardiac surgical ERAS practices published in 2019, aimed at improving outcomes in cardiac surgery.

The recommendations are arranged into pre-operative, intraoperative, and post-operative strategies. The strength of statements depend on the class of recommendation and level (quality) of evidence.

Pre-operative Recommendations

Preoperative assessment of Hemoglobin A1c can be used to stratify the risks of the patinets undergoing cardiac surgery. (class IIa, level C-LD) Evidence suggests that adequate pre-operative glycaemic control with HbA1C <6.5 is associated with reduced surgical site infections and ischaemic complications.

Preoperative level of albumin can be used to stratify the risks of the patients undergoing cardiac surgery. (class IIa, level C-LD) Low albumin is associated with raised infections, ventilator time, kidney injury.

Rectification of nutritional deficiency is suggested when possible and can improve the outcomes. (class IIa, level C-LD) Preoperative intensive nutrition therapy for 7 to 10 days in patients with albumin <3 gm/dl and undergoing cardiac surgery can decrease many perioperative complications.

Clear liquids can be allowed up to 2 to 4 hours before general anaesthesia. (class IIb, level C-LD) However it should be kept in mind that aspiration pneumonia can be a potential threat in diabetic patients with delayed gastric emptying and with the use of transesophageal echocardiography. A Cochrane review suggested that preoperative carbohydrate loading (2-hour preoperative 24-g complex carbohydrate beverage) decreases the likelihood of insulin resistance and hospital stay. However, it has been given a weak recommendation owing to minimal supportive data. (class IIb, level C-LD)

Patient education and counseling prior to surgery, in person or via digital material should be routinely practiced. (class IIa, level C-LD) It improves perioperative anxiety, and health outcome.

A cardiac prehabilitation program comprising of nutritional optimisation, exercise training, education, anxiety reduction, and social support prepares the patient for surgery psychologically and physically. (class IIa, level B-NR) However, this may not be feasible in emergency scenarios.

Smoking and alcohol abstinence for 1 month yields enhanced recovery and post-operative outcomes after surgery. (class I, level C-LD) However, again this may not be feasible in emergency scenarios.

Intraoperative recommendations

The ERAS CS program has introduced a care bundle to reduce surgical site infections.

1. Pre-operative, topical, intranasal decolonisation should be performed with agents such as mupirocin (I A)
2. For pre-incision 30 to 60 minutes prior to surgery, use intravenous prophylactic antibiotic cephalosporin. (I A)
3. Clipping should be preferred immediately prior to surgery; not shaving.(I C)
4. Preoperative use of chlorhexidine alcohol-based solution for skin preparation is recommended. (IIb C)
5. Sterile dressing removal done within 48 hours is beneficial. (IIa C)
6. Hyperthermia while rewarming on cardiopulmonary bypass should be avoided (class III, level B-R) Core temperature >37.9°C is associated with infections, kidney dysfunction and cognitive dysfunction.
7. Rigid sternal fixation (as compared to wire cerclage for sternotomy closure) promotes sternal healing and reduces mediastinitis. (class IIa, level B-R) This should be particularly considered in patients with high BMI, steroid use, and severe COPD.
8. Antifibrinolytics- tranexamic acid or epsilon aminocaproic acid should be used during on-pump cardiac surgical procedures. (class I, level A) It reduces perioperative blood product transfusions and re-exploration rates.

Postoperative recommendations

1. Perioperative glycaemic control improves outcomes in cardiac surgery population. (class I, level B-R) The Society of Thoracic Surgery (STS) guidelines recommend maintaining perioperative blood glucose <180 mg/dl while avoiding hypoglycaemia.
2. Titrated insulin infusion improves perioperative glycaemic control. (class IIa, level B-NR)
3. Multimodal opioid-sparing approaches such as paracetamol, tramadol, dexmedetomidine, gabapentin, and pregabalin can improve perioperative analgesia. (class I, level B-NR)
4. Non-steroidal anti-inflammatory drugs are associated with kidney dysfunction and potential thromboembolic events.
5. Delirium is seen in about 50% of cardiac surgery patients. A delirium screening tool such as confusion assessment method for the intensive care unit or intensive care unit delirium screening checklist should be routinely used to identify patients at risk and take steps for prevention and treatment protocol. (class I, level B-NR)
6. Hypothermia should be avoided in the early postoperative period by using warm intravenous fluids, warming blankets and maintaining room temperature. (class 1, level B-NR) Hypothermia raises the risks of infections, bleeding, and other complications.
7. Chest tube patency should be maintained without breaking the sterility. It is highly recommended to avoid collected blood complications. (class I, level B-NR) Breaching the sterile field of chest tubes or stripping to remove a clot should never be preferred. (class IIIA, level B-R) Recently, active chest-tube clearance methods are effectively used to maintain the chest tube patency and reduce the related complications such as postoperative atrial fibrillations.
8. Mechanical (DVT pump) and pharmacological thromboprophylaxis (anticoagulant) should be used to reduce vascular thrombotic events (generally on POD 1 through discharge). (class IIa, level C-LD)
9. Strategies for extubation within 6 hours of surgery can effectively reduce ventilator-associated complications and dysphagia. (class IIa, level B-NR) This has been found to be safe even in high-risk patients.
10. Biomarkers such as tissue inhibitor of metalloproteinases-2 and insulin like growth factor-binding protein 7 can be used for early detection of patients at risk of renal dysfunction and guide an intervention strategy to reduce AKI. (class IIa, level B-R) Avoiding nephrotoxic agents and drugs like ACEI, optmising volume status, haemodynamics and avoiding hyperglycaemia are effective strategies.
11. As in non-cardiac surgery, goal-directed fluid therapy is also beneficial to reduce postoperative complications in cardiac surgery. (class I, level B-R)

The ERAS program is relatively new in the cardiac surgery speciality. These guidelines can surely benefit the patients by improving quality, safety and care.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Monish S Raut is a Consultant in Cardiothoracic Vascular Anaesthesiology. His area of expertise is perioperative management and echocardiography with numerous publications in various national and international indexed journals.