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Diz-Ferreira E, Díaz-Vidal P, Fernández-Vázquez U, Gil-Casado C, Luna-Rojas P, Diz JC. Effect of Enhanced Recovery After Surgery (ERAS) Programs on Perioperative Outcomes in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2025; 39:1325-1334. [PMID: 39952836 DOI: 10.1053/j.jvca.2025.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 12/13/2024] [Accepted: 01/27/2025] [Indexed: 02/17/2025]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs emerged as a strategy to reduce perioperative morbidity; however, there is currently limited evidence of their clinical efficacy. The objective of this study was to assess the impact of ERAS programs in cardiac surgery on hospital length of stay, mortality, atrial fibrillation, and quality of life. METHODS A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, encompassing studies on ERAS programs in adult patients undergoing elective cardiac surgery. The effect size and 95% confidence interval (CI) were estimated with a random-effects model. The protocol was preregistered on Open Science Framework. RESULTS Eighteen studies (published between 2016 and 2023) comprising 4,469 patients were included in the analysis, of which only one was a randomized controlled trial. The implementation of ERAS was associated with a reduction in hospital stay of 1.24 days (95% CI: -1.67, -0.82, p < 0.001, I2 = 83%). No differences were observed between the groups in mortality (odds ratio: 0.65, 95% CI: 0.28, 1.48, p = 0.3, I2 = 0%), nor in the incidence of atrial fibrillation (odds ratio: 0.77, 95% CI: 0.57, 1.03, p = 0.08, I2 = 17%). A meta-analysis of quality of life was not feasible due to a lack of sufficient data. CONCLUSIONS Although ERAS programs were associated with a reduction in hospital stay and no differences in mortality or atrial fibrillation, the quality of the evidence was very low. To recommend the implementation of ERAS programs in cardiac surgery, it is necessary to have randomized studies providing evidence of its efficacy, and studies including quality of life and other patient-centered recovery criteria outcomes.
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Affiliation(s)
- Eva Diz-Ferreira
- Well-Move Research Group, University of Vigo, School of Medicine, University of Santiago de Compostela, Spain
| | | | | | | | | | - José Carlos Diz
- Department of Anesthesia and Postoperative Critical Care, Hospital Alvaro Cunqueiro, Vigo, Department of Functional Biology and Health Sciences, Well-Move Research Group, University of Vigo, Spain.
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Othenin-Girard A, Ltaief Z, Verdugo-Marchese M, Lavanchy L, Vuadens P, Nowacka A, Gunga Z, Melly V, Abdurashidova T, Botteau C, Hennemann M, Graf J, Schoettker P, Kirsch M, Rancati V. Enhanced Recovery After Surgery (ERAS) Protocols in Cardiac Surgery: Impact on Opioid Consumption. J Clin Med 2025; 14:1768. [PMID: 40095860 PMCID: PMC11901073 DOI: 10.3390/jcm14051768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/03/2025] [Accepted: 03/04/2025] [Indexed: 03/19/2025] Open
Abstract
Background: Enhanced Recovery After Surgery (ERAS) protocols have been implemented in various surgical specialties to improve patient outcomes and reduce opioid consumption. In cardiac surgery, the traditionally high-dose opioid use is associated with prolonged ventilation, intensive care unit (ICU) stays, and opioid-related adverse drug events (ORADEs). This study evaluates the impact of an ERAS® Society-certified program on opioid consumption in patients undergoing elective cardiac surgery at Lausanne University Hospital. Methods: A retrospective, monocentric observational study was conducted comparing two patient cohorts: one treated with ERAS protocols (2023-2024) and a retrospective control group from 2019. Data were collected from the hospital's electronic medical records and the ERAS program database. The primary outcome was total opioid consumption, measured intraoperatively and postoperatively (postoperative day (POD) 0-3). Secondary outcomes included pain control, length of stay, complications, and recovery parameters. Statistical analyses included multivariate logistic regression to identify factors associated with reduced opioid consumption. Results: Patients in the ERAS group demonstrated significantly lower total opioid consumption, whether intraoperatively (median sufentanil: 40 mcg vs. 51 mcg, p < 0.0001) or postoperatively (POD 0-3: p < 0.001). The ERAS group had faster extubation times, earlier mobilization and pain control with non-opioid analgesics, fewer complications, and shorter hospital stays (9 vs. 12 days, p < 0.001). Logistic regression identified fast-track extubation and absence of complications as strong predictors of reduced opioid use. Conclusions: The implementation of an ERAS protocol in cardiac surgery significantly reduces opioid consumption while enhancing recovery.
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Affiliation(s)
- Alexandra Othenin-Girard
- Department of Anesthesia, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (A.O.-G.); (L.L.); (P.V.); (P.S.)
| | - Zied Ltaief
- Department of Intensive Care, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland;
| | - Mario Verdugo-Marchese
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
| | - Luc Lavanchy
- Department of Anesthesia, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (A.O.-G.); (L.L.); (P.V.); (P.S.)
| | - Patrice Vuadens
- Department of Anesthesia, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (A.O.-G.); (L.L.); (P.V.); (P.S.)
| | - Anna Nowacka
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
| | - Ziyad Gunga
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
| | - Valentine Melly
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
| | - Tamila Abdurashidova
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
| | - Caroline Botteau
- Department of Cardio-Respiratory Physiotherapy, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (C.B.); (M.H.)
| | - Marius Hennemann
- Department of Cardio-Respiratory Physiotherapy, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (C.B.); (M.H.)
| | - Jérôme Graf
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland;
| | - Patrick Schoettker
- Department of Anesthesia, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (A.O.-G.); (L.L.); (P.V.); (P.S.)
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland;
| | - Matthias Kirsch
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (M.V.-M.); (A.N.); (Z.G.); (V.M.); (T.A.); (M.K.)
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1011 Lausanne, Switzerland;
| | - Valentina Rancati
- Department of Anesthesia, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland; (A.O.-G.); (L.L.); (P.V.); (P.S.)
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Malvindi PG, Bifulco O, Berretta P, Galeazzi M, Alfonsi J, Cefarelli M, Zingaro C, Zahedi HM, Munch C, Di Eusanio M. The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies. J Clin Med 2024; 13:2903. [PMID: 38792445 PMCID: PMC11121940 DOI: 10.3390/jcm13102903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Hossein M. Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
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Desai S, Carbonell C, Hoffman K, Hammond B, Crosier C, Blackhurst D, Carbonell AM, Love MW, Cobb WS, Warren JA. Impact of methocarbamol on opioid use after ventral incisional hernia repair. Am J Surg 2023; 226:858-863. [PMID: 37481407 DOI: 10.1016/j.amjsurg.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.
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Affiliation(s)
| | - Cecilia Carbonell
- Prisma Health Department of Surgery, Summer Program for Undergraduate Research in Surgery, USA
| | | | - Brooke Hammond
- Prisma Health Department of Surgery, Summer Program for Undergraduate Research in Surgery, USA
| | | | | | - Alfredo M Carbonell
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA
| | | | - William S Cobb
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA
| | - Jeremy A Warren
- Prisma Health Department of Surgery, USA; University of South Carolina School of Medicine Greenville, USA.
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