Abstract
Protocols for “Enhanced recovery after surgery (ERAS)” are on the rise in different surgical disciplines and represent one of the most important recent advancements in perioperative medical care. In cardiac surgery, only few ERAS protocols have been described in the past. At University Heart Center Hamburg, Germany, we invented an ERAS protocol for patients undergoing minimally invasive cardiac valve surgery. In this retrospective single center study, we aimed to describe the implementation of our ERAS program and to evaluate the results of the first 50 consecutive patients. Our ERAS protocol was developed according to a modified Kern cycle by an expert group, literature search, protocol creation and pilot implementation in the clinical practice. Data of the first 50 consecutive patients undergoing minimally invasive cardiac valve surgery were analysed retrospectively. The key features of our multidisciplinary ERAS protocol are physiotherapeutic prehabilitation, minimally invasive valve surgery techniques, modified cardiopulmonary bypass management, fast-track anaesthesia with on- table extubation and early mobilisation. A total of 50 consecutive patients (mean age of 51.9±11.9 years, mean STS score of 0.6±0.3) underwent minimally-invasive mitral or aortic valve surgery. The adherence to the ERAS protocol was high and neither protocol related complications nor in-hospital mortality occurred. 12% of the patients developed postoperative atrial fibrillation, postoperative delirium emerged in two patients and reintubation was required in one patient. Intensive care unit stay was 14.0±7.4 hours and total hospital stay 6.2±2.9 days. Our ERAS protocol is feasible and safe in minimally-invasive cardiac surgery setting and has a clear potential to improve patients outcome.
Highlights
One of the most important improvements in contemporary perioperative medicine has been the establishment of enhanced recovery after surgery (ERAS) protocols in surgery [1]
An ERAS protocol is a multidisciplinary and multiprofessional effort including: (1) an improvement of the preoperative physical and mental status (2) a modification of the intraoperative management by standardized minimally-invasive surgery and an early extubation, and (3) an implementation of enhanced postoperative recovery protocol integrating an individualized analgesia and standardized physiotherapeutic program. Those are the key features of an integrative ERAS protocol which extends beyond the intraoperative phase
We introduce the patients into the physiotherapy protocol during the pre-operative consultation which includes teaching on the breathing coach and respiratory exercises to prevent post-operative atelectasis and pneumonia
Summary
One of the most important improvements in contemporary perioperative medicine has been the establishment of enhanced recovery after surgery (ERAS) protocols in surgery [1]. An ERAS protocol is a multidisciplinary and multiprofessional effort including: (1) an improvement of the preoperative physical and mental status (e.g., exercising the cardio-pulmonary capacity and optimization of the nutritional status) (2) a modification of the intraoperative management by standardized minimally-invasive surgery and an early extubation, and (3) an implementation of enhanced postoperative recovery protocol integrating an individualized analgesia and standardized physiotherapeutic program. Those are the key features of an integrative ERAS protocol which extends beyond the intraoperative phase. The ERAS society has developed protocols for pancreatic surgery [6, 7], bariatrics [8], urology [9] and gynaecology/ obstetrics [10] which all have been certified by the ERAS Society
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