Interpretation of 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)_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

MENG Yanhai ¹ , CHANG Shuo ¹ , SHANG Jigao ¹ , LI Zemeng ¹ ,  ZHANG Yanbo ¹ ,  WANG Shuiyun ²

1. Adult Surgery ICU, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P. R. China;
2. Adult Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

ZHANG Yanbo, Email: yanbozhang@126.com; WANG Shuiyun, Email: wsymd@sina.com

Keywords：

Enhanced recovery after surgery; cardiac surgery; perioperative period; consensus; interpretation

DOI：

10.7507/1007-4848.202408047

Video：

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Enhanced recovery after surgery (ERAS) has been proven to reduce surgical injuries, promote recovery, and improve postoperative outcomes in different types of surgeries. A core principle of ERAS is to provide programmatic evidence-based perioperative interventions. An international multidisciplinary expert group provided a statement on clinical practice in each thematic area of ERAS by obtaining a list of potential ERAS elements, and reviewing literature. The version 2024 of "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)" is developed from the version 2019 of "Guidelines for perioperative care in cardiac surgery: Enhanced Recovery after Surgery Society recommendations". The consensus statement group was composed of multidisciplinary experts such as cardiac surgeons, anesthesiologists, intensive care physicians, and nurses, based on personal ERAS knowledge and experience. This article interprets the changes and new statements in the 2024 consensus, which can provide a foundation for the best perioperative practices for adult cardiac surgery patients.

1.	Grant MC, Crisafi C, Alvarez A, et al. 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). Ann Thorac Surg, 2024, 117(4): 669-689.
2.	Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery after Surgery Society recommendations. JAMA Surg, 2019, 154(8): 755-766.
3.	白松杰, 曾冰, 黄志勇. 2019年欧洲加速康复外科协会《心脏手术围术期管理指南》解读. 中国胸心血管外科临床杂志, 2020, 27(2): 206-208.Bai SJ, Zeng B, Huang ZY. Interpretation of the 2019 European Association for Accelerated Rehabilitation Surgery guidelines for perioperative management of cardiac surgery. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(2): 206-208.
4.	Flynn BC, Shelton K. On the 2024 Cardiac Surgical Enhanced Recovery after Surgery (ERAS) joint consensus statement. J Cardiothorac Vasc Anesth, 2024, 38(8): 1615-1619.
5.	Stenberg E, Dos Reis Falcão LF, O'Kane M, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery after Surgery (ERAS) Society recommendations: A 2021 update. World J Surg, 2022, 46(4): 729-751.
6.	Cook DJ, Manning DM, Holland DE, et al. Patient engagement and reported outcomes in surgical recovery: Effectiveness of an e-health platform. J Am Coll Surg, 2013, 217(4): 648-655.
7.	Ljungqvist O, de Boer HD, Balfour A, et al. Opportunities and challenges for the next phase of enhanced recovery after surgery: A review. JAMA Surg, 2021, 156(8): 775-784.
8.	Jacobs JP, Shahian DM, Grau-Sepulveda M, et al. Current penetration, completeness, and representativeness of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg, 2022, 113(5): 1461-1468.
9.	Hensley NB, Grant MC, Cho BC, et al. How do we use dashboards to enhance quality in cardiac anesthesia? J Cardiothorac Vasc Anesth, 2021, 35(10): 2969-2976.
10.	Pittams AP, Iddawela S, Zaidi S, et al. Scoring systems for risk stratification in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth, 2022, 36(4): 1148-1156.
11.	Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg, 2011, 213(1): 37-42.
12.	Lee DH, Buth KJ, Martin BJ, et al. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation, 2010, 121(8): 973-978.
13.	Tam DY, Qiu F, Manoragavan R, et al. The impact of the COVID-19 pandemic on cardiac procedure wait list mortality in Ontario, Canada. Can J Cardiol, 2021, 37(10): 1547-1554.
14.	Stoppe C, Whitlock R, Arora RC, et al. Nutrition support in cardiac surgery patients: Be calm and feed on. J Thorac Cardiovasc Surg, 2019, 158(4): 1103-1108.
15.	No authors listed. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to reduce the risk of pulmonary aspiration. Anesthesiology, 2017, 126(3): 376-393.
16.	MacKay EJ, Zhang B, Augoustides JG, et al. Association of intraoperative transesophageal echocardiography and clinical outcomes after open cardiac valve or proximal aortic surgery. JAMA Netw Open, 2022, 5(2): e2147820.
17.	Zochios V, Klein AA, Gao F. Protective invasive ventilation in cardiac surgery: A systematic review with a focus on acute lung injury in adult cardiac surgical patients. J Cardiothorac Vasc Anesth, 2018, 32(4): 1922-1936.
18.	Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med, 2013, 369(5): 428-437.
19.	Aoyama H, Pettenuzzo T, Aoyama K, et al. Association of driving pressure with mortality among ventilated patients with acute respiratory distress syndrome: A systematic review and meta-analysis. Crit Care Med, 2018, 46(2): 300-306.
20.	Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery. Anesthesiology, 2019, 131(5): 1046-1062.
21.	Bignami E, Guarnieri M, Saglietti F, et al. Mechanical ventilation during cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2016, 30(6): 1668-1675.
22.	Nguyen LS, Estagnasie P, Merzoug M, et al. Low tidal volume mechanical ventilation against no ventilation furing vardiopulmonary bypass in heart surgery (MECANO): A randomized controlled trial. Chest, 2021, 159(5): 1843-1853.
23.	Chiang Y, Hosseinian L, Rhee A, et al. Questionable benefit of the pulmonary artery catheter after cardiac surgery in high-risk patients. J Cardiothorac Vasc Anesth, 2015, 29(1): 76-81.
24.	Zorrilla-Vaca A, Healy R, Grant MC, et al. Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: A meta-analysis of randomized controlled trials. Can J Anaesth, 2018, 65(5): 529-542.
25.	Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg, 2020, 131(2): 411-448.
26.	Ranucci M, Romitti F, Isgrò G, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg, 2005, 80(6): 2213-2220.
27.	Brovman EY, Tolis G, Hirji S, et al. Association between early extubation and postoperative reintubation after elective cardiac surgery: A bi-institutional study. J Cardiothorac Vasc Anesth, 2022, 36(5): 1258-1264.
28.	Grant MC, Isada T, Ruzankin P, et al. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg, 2020, 159(4): 1393-1402.
29.	Dorsa AG, Rossi AI, Thierer J, et al. Immediate extubation after off-pump coronary artery bypass graft surgery in 1 196 consecutive patients: Feasibility, safety and predictors of when not to attempt it. J Cardiothorac Vasc Anesth, 2011, 25(3): 431-436.
30.	Zhang H, Lang H, Ma M, et al. Decreased preoperative urinary uromodulin as a predictor of acute kidney injury and perioperative kidney dysfunction in patients undergoing cardiac surgery: A prospective cohort study. Clin Chim Acta, 2022, 530: 1-7.
31.	Engelman DT, Crisafi C, Germain M, et al. Using urinary biomarkers to reduce acute kidney injury following cardiac surgery. J Thorac Cardiovasc Surg, 2020, 160(5): 1235-1246.
32.	Doyle MP, Indraratna P, Tardo DT, et al. Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis. Eur J Prev Cardiol, 2019, 26(1): 36-45.
33.	Pengelly J, Pengelly M, Lin KY, et al. Resistance training following median sternotomy: A systematic review and meta-analysis. Heart Lung Circ, 2019, 28(10): 1549-1559.
34.	Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. JAMA Surg, 2017, 152(7): 691-697.
35.	Guay J, Kopp S. Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass. Cochrane Database Syst Rev, 2019, 3(3): CD006715.
36.	Jack JM, McLellan E, Versyck B, et al. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: A qualitative systematic review. Anaesthesia, 2020, 75(10): 1372-1385.
37.	Salenger R, Hirji S, Rea A, et al. ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023. J Thorac Cardiovasc Surg, 2024, 168(3): 890-897.e4.
38.	Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: A systematic review and meta-analysis. Ann Surg, 2019, 269(5): 794-804.
39.	Chen YL, Zeng M, Liu Y, et al. CHA2DS2-VASc score for identifying patients at high risk of postoperative atrial fibrillation after cardiac surgery: A meta-analysis. Ann Thorac Surg, 2020, 109(4): 1210-1216.
40.	Dubiel C, Hiebert BM, Stammers AN, et al. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg, 2022, 163(2): 725-734.
41.	Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med, 2018, 379(26): 2506-2516.
42.	Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med, 2018, 46(9): e825-e873.
43.	Keenan JE, Speicher PJ, Thacker JK, et al. The preventive surgical site infection bundle in colorectal surgery: An effective approach to surgical site infection reduction and health care cost savings. JAMA Surg, 2014, 149(10): 1045-1052.

1. Grant MC, Crisafi C, Alvarez A, et al. 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). Ann Thorac Surg, 2024, 117(4): 669-689.
2. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery after Surgery Society recommendations. JAMA Surg, 2019, 154(8): 755-766.
3. 白松杰, 曾冰, 黄志勇. 2019年欧洲加速康复外科协会《心脏手术围术期管理指南》解读. 中国胸心血管外科临床杂志, 2020, 27(2): 206-208.Bai SJ, Zeng B, Huang ZY. Interpretation of the 2019 European Association for Accelerated Rehabilitation Surgery guidelines for perioperative management of cardiac surgery. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(2): 206-208.
4. Flynn BC, Shelton K. On the 2024 Cardiac Surgical Enhanced Recovery after Surgery (ERAS) joint consensus statement. J Cardiothorac Vasc Anesth, 2024, 38(8): 1615-1619.
5. Stenberg E, Dos Reis Falcão LF, O'Kane M, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery after Surgery (ERAS) Society recommendations: A 2021 update. World J Surg, 2022, 46(4): 729-751.
6. Cook DJ, Manning DM, Holland DE, et al. Patient engagement and reported outcomes in surgical recovery: Effectiveness of an e-health platform. J Am Coll Surg, 2013, 217(4): 648-655.
7. Ljungqvist O, de Boer HD, Balfour A, et al. Opportunities and challenges for the next phase of enhanced recovery after surgery: A review. JAMA Surg, 2021, 156(8): 775-784.
8. Jacobs JP, Shahian DM, Grau-Sepulveda M, et al. Current penetration, completeness, and representativeness of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg, 2022, 113(5): 1461-1468.
9. Hensley NB, Grant MC, Cho BC, et al. How do we use dashboards to enhance quality in cardiac anesthesia? J Cardiothorac Vasc Anesth, 2021, 35(10): 2969-2976.
10. Pittams AP, Iddawela S, Zaidi S, et al. Scoring systems for risk stratification in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth, 2022, 36(4): 1148-1156.
11. Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg, 2011, 213(1): 37-42.
12. Lee DH, Buth KJ, Martin BJ, et al. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation, 2010, 121(8): 973-978.
13. Tam DY, Qiu F, Manoragavan R, et al. The impact of the COVID-19 pandemic on cardiac procedure wait list mortality in Ontario, Canada. Can J Cardiol, 2021, 37(10): 1547-1554.
14. Stoppe C, Whitlock R, Arora RC, et al. Nutrition support in cardiac surgery patients: Be calm and feed on. J Thorac Cardiovasc Surg, 2019, 158(4): 1103-1108.
15. No authors listed. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to reduce the risk of pulmonary aspiration. Anesthesiology, 2017, 126(3): 376-393.
16. MacKay EJ, Zhang B, Augoustides JG, et al. Association of intraoperative transesophageal echocardiography and clinical outcomes after open cardiac valve or proximal aortic surgery. JAMA Netw Open, 2022, 5(2): e2147820.
17. Zochios V, Klein AA, Gao F. Protective invasive ventilation in cardiac surgery: A systematic review with a focus on acute lung injury in adult cardiac surgical patients. J Cardiothorac Vasc Anesth, 2018, 32(4): 1922-1936.
18. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med, 2013, 369(5): 428-437.
19. Aoyama H, Pettenuzzo T, Aoyama K, et al. Association of driving pressure with mortality among ventilated patients with acute respiratory distress syndrome: A systematic review and meta-analysis. Crit Care Med, 2018, 46(2): 300-306.
20. Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery. Anesthesiology, 2019, 131(5): 1046-1062.
21. Bignami E, Guarnieri M, Saglietti F, et al. Mechanical ventilation during cardiopulmonary bypass. J Cardiothorac Vasc Anesth, 2016, 30(6): 1668-1675.
22. Nguyen LS, Estagnasie P, Merzoug M, et al. Low tidal volume mechanical ventilation against no ventilation furing vardiopulmonary bypass in heart surgery (MECANO): A randomized controlled trial. Chest, 2021, 159(5): 1843-1853.
23. Chiang Y, Hosseinian L, Rhee A, et al. Questionable benefit of the pulmonary artery catheter after cardiac surgery in high-risk patients. J Cardiothorac Vasc Anesth, 2015, 29(1): 76-81.
24. Zorrilla-Vaca A, Healy R, Grant MC, et al. Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: A meta-analysis of randomized controlled trials. Can J Anaesth, 2018, 65(5): 529-542.
25. Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg, 2020, 131(2): 411-448.
26. Ranucci M, Romitti F, Isgrò G, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg, 2005, 80(6): 2213-2220.
27. Brovman EY, Tolis G, Hirji S, et al. Association between early extubation and postoperative reintubation after elective cardiac surgery: A bi-institutional study. J Cardiothorac Vasc Anesth, 2022, 36(5): 1258-1264.
28. Grant MC, Isada T, Ruzankin P, et al. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg, 2020, 159(4): 1393-1402.
29. Dorsa AG, Rossi AI, Thierer J, et al. Immediate extubation after off-pump coronary artery bypass graft surgery in 1 196 consecutive patients: Feasibility, safety and predictors of when not to attempt it. J Cardiothorac Vasc Anesth, 2011, 25(3): 431-436.
30. Zhang H, Lang H, Ma M, et al. Decreased preoperative urinary uromodulin as a predictor of acute kidney injury and perioperative kidney dysfunction in patients undergoing cardiac surgery: A prospective cohort study. Clin Chim Acta, 2022, 530: 1-7.
31. Engelman DT, Crisafi C, Germain M, et al. Using urinary biomarkers to reduce acute kidney injury following cardiac surgery. J Thorac Cardiovasc Surg, 2020, 160(5): 1235-1246.
32. Doyle MP, Indraratna P, Tardo DT, et al. Safety and efficacy of aerobic exercise commenced early after cardiac surgery: A systematic review and meta-analysis. Eur J Prev Cardiol, 2019, 26(1): 36-45.
33. Pengelly J, Pengelly M, Lin KY, et al. Resistance training following median sternotomy: A systematic review and meta-analysis. Heart Lung Circ, 2019, 28(10): 1549-1559.
34. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. JAMA Surg, 2017, 152(7): 691-697.
35. Guay J, Kopp S. Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass. Cochrane Database Syst Rev, 2019, 3(3): CD006715.
36. Jack JM, McLellan E, Versyck B, et al. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: A qualitative systematic review. Anaesthesia, 2020, 75(10): 1372-1385.
37. Salenger R, Hirji S, Rea A, et al. ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023. J Thorac Cardiovasc Surg, 2024, 168(3): 890-897.e4.
38. Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: A systematic review and meta-analysis. Ann Surg, 2019, 269(5): 794-804.
39. Chen YL, Zeng M, Liu Y, et al. CHA2DS2-VASc score for identifying patients at high risk of postoperative atrial fibrillation after cardiac surgery: A meta-analysis. Ann Thorac Surg, 2020, 109(4): 1210-1216.
40. Dubiel C, Hiebert BM, Stammers AN, et al. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg, 2022, 163(2): 725-734.
41. Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med, 2018, 379(26): 2506-2516.
42. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med, 2018, 46(9): e825-e873.
43. Keenan JE, Speicher PJ, Thacker JK, et al. The preventive surgical site infection bundle in colorectal surgery: An effective approach to surgical site infection reduction and health care cost savings. JAMA Surg, 2014, 149(10): 1045-1052.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesInterpretation of 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)

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