Table 2.
Key actions included in the ERAS protocols grouped according to each perioperative stage and their level of evidence (LOE) as recognised by the latest Consensus Guidelines and Statement on ERAS in cardiac surgery.
| Action | Details | N of Studies | References | LOE in Engelman et al. [13] |
LOE in Grant et al. [29] |
|---|---|---|---|---|---|
| Preoperative | |||||
| Preoperative assessment, education | Personal meeting, video tutorial, pamphlet | 10 | [15,17,18,19,20,21,22,24,25,26] | IIa C | Moderate Low |
| Preoperative psychological counselling | 2 | [15,21] | |||
| Prehabilitation | Pamphlet with exercises; in-person meeting with physiotherapist(s) | 6 | [17,19,20,21,25,26] | IIa B | Low |
| Diet improvement | High-energy, high-carbohydrate diet | 7 | [19,20,21,24,25,26,28] | IIa C | |
| Smoking and alcohol cessation | 5 | [17,19,22,26,28] | I C | ||
| EPO therapy from admission to hospital | 1 | [15] | |||
| Shorten nihil per os time and carbohydrate beverage intake before anaesthesia | Up to 2–6 h before anaesthesia | 9 | [15,16,17,18,19,22,25,26,28] | IIb C | Low |
| No preoperative sedative or anticholinergic drug use | 3 | [15,25,26] | |||
| Preoperative analgesia | Paracetamol, gabapentin, pregabalin | 7 | [16,17,18,19,20,22,24] | I B | |
| Intraoperative | |||||
| Multimodal analgesia | Including locoregional analgesia: paravertebral block, infiltration at the incision site | 10 | [15,19,20,21,22,23,24,25,26,28] | I B | Moderate |
| Fast-track cardiac anaesthesia with short-acting narcotic and sedative agents | 6 | [15,17,19,22,25,28] | IIa B | Moderate | |
| Optimisation of CPB | MIECC, fluid reduction, flow | 6 | [15,20,21,25,26,28] | Low | |
| Lung protection strategy | Low tidal volume (6–8 mL/kg) ventilation, positive end-expiratory pressure, lung recruitment manoeuvre | 3 | [15,20,26] | High | |
| Fluid management | Goal-directed (TOE-guided) | 8 | [15,19,20,21,22,24,25,26] | I B | Moderate |
| Blood conservation measures and transfusion | Cell saver, antiplasmin agent, antifibrinolytic and TEG monitor | 5 | [15,20,24,26,28] | I A | Moderate |
| Temperature control | 5 | [17,19,22,26,28] | I B | ||
| Surgical access | Sternotomy and minimally invasive access | 4 | [20,21,25,28] | ||
| Postoperative | |||||
| Early extubation | On table ICU early extubation |
9 | [17,19,20,21,22,25,26,27,28] | IIa B | Low Moderate |
| Multimodal postoperative analgesia | Patient-controlled analgesia, regional analgesia, infiltration at incision site | 11 | [15,17,18,19,21,22,23,25,26,27,28] | I B | Moderate |
| Postoperative nausea and vomiting prevention | Usually i.v. ondansetron | 8 | [15,16,17,18,19,22,25,26] | Moderate | |
| Atrial fibrillation prevention | 2 | [16,21] | Moderate | ||
| Delirium screening/prevention | 3 | [20,24,28] | I B | High | |
| Early oral intake after tracheal extubation | Usually from 6 h since extubation | 4 | [15,17,26,28] | ||
| Early removal of drainage tube | No clear criteria | 7 | [15,20,21,22,24,25,26,28] | ||
| Early removal of urinary catheter | No clear criteria | 5 | [20,21,22,25,26] | ||
| Early removal of central venous line | Venous line removed at discharge from ICU/removed approximately after 12 h | 4 | [20,21,22,26] | ||
| Early physiotherapy and mobilisation as soon as possible | From 3 h since extubation. Different protocols including chest physiotherapy, bed activities and full mobilisation within 12–24 h | 11 | [14,15,17,18,19,20,21,22,25,26,27,28] | Moderate | |
| Early contact with family | 1 | [28] |