Effects of Implementing an Enhanced Recovery After Cardiac Surgery Protocol with On-Table Extubation on Patient Outcome and Satisfaction—A Before–After Study

Q: What are the key findings of this study?

Implementing an ERAS protocol with on-table extubation reduced postoperative ICU stay and hospital length of stay compared to standard care.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Elective coronary artery bypass surgery or aortic valve replacement surgery (n=233). Intervention: Enhanced Recovery After Cardiac Surgery protocol with on-table extubation (RERACS) vs. Retrospective standard perioperative care with delayed extubation in the ICU. Primary outcome: Postoperative hospital length of stay (days) (p=0.028).

Q: What does this research mean for the field?

Implementing an enhanced recovery after surgery (ERAS) protocol with on-table extubation in elective cardiac surgery significantly reduces ICU and hospital length of stay, catecholamine dependency, and postoperative complications. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

A. Werner; H Conrads; Johanna Rosenberger; Marcus Creutzenberg; Bernhard Gräf; Maik Foltan; Sebastian Blecha; Andrea Stadlbauer; Bernhard Floerchinger; Maria Tafelmeier; Michael Arzt; Çhristof Schmid; Diane Bitzinger

doi:10.3390/jcm14020352

January 8, 2025Journal of Clinical MedicineOpen Access

Effects of Implementing an Enhanced Recovery After Cardiac Surgery Protocol with On-Table Extubation on Patient Outcome and Satisfaction—A Before–After Study

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Key result

Cardiac ERAS with on-table extubation linked to ~2-day shorter hospital stay vs. standard care.

P=0.028
n=233

Figures

Why the study?

Enhanced recovery after surgery protocols are less established in cardiac surgery, particularly in combination with on-table extubation.

Does implementing an Enhanced Recovery After Cardiac Surgery protocol with on-table extubation (RERACS) reduce postoperative length of stay and complications while improving recovery in patients undergoing elective coronary bypass or aortic valve replacement surgery?

Key Points

Evaluate the impact of an enhanced recovery after surgery protocol combining on-table extubation with multimodal perioperative care on clinical outcomes, length of stay, and patient satisfaction in elective cardiac surgery.
Monocentric before–after study comparing a prospective intervention group (n = 114) receiving the RERACS protocol to a retrospective standard-care control group (n = 119) undergoing elective aortic valve replacement or coronary bypass surgery (DRKS00031402).
The RERACS protocol incorporated preoperative respiratory muscle training, shortened fasting with carbohydrate loading, opioid-sparing multimodal analgesia, and planned on-table extubation.
Postoperative intensive care unit stay (40 ± 34 h vs. 56 ± 51 h, p = 0.005) and total hospital stay (9 ± 4 d vs. 11 ± 6 d, p = 0.028) were significantly shorter in the RERACS group compared to standard care.
Vasoactive catecholamine therapy duration was significantly lower in the RERACS group (22 ± 30 h vs. 42 ± 48 h, p < 0.001).
RERACS patients experienced fewer nosocomial infections (24% vs. 40%), reduced cognitive dysfunction or delirium (40% vs. 57%), and lower rates of postoperative nausea and vomiting (14.9% vs. 32.8%).

Study Design

Type

Cohort (n=233)

Multicenter

No

Structured PICO

Does implementing an Enhanced Recovery After Cardiac Surgery protocol with on-table extubation (RERACS) reduce postoperative length of stay and complications while improving recovery in patients undergoing elective coronary bypass or aortic valve replacement surgery?

P

Population

233 adults aged 18-75 years undergoing elective coronary bypass or aortic valve replacement surgery with left ventricular function >30% and cardiopulmonary stability at a single German center.

I

Intervention

Regensburg Enhanced Recovery After Cardiac Surgery (RERACS) protocol with on-table extubation (OTE). Preoperative: respiratory training (hourly max inspiration with a respiratory trainer), minimized fasting (solids up to 6 h, 350 mL sweetened tea up to 2 h before induction), avoidance of sedating premedication. Intraoperative: anesthesia induction with sufentanil bolus (0.5 µg/kg ABW), propofol (1–2 mg/kg ABW), and rocuronium (0.6 mg/kg ABW); maintenance with sevoflurane (0.7–0.9 MAC), dexmedetomidine starting at CPB (40–80 µg/h), and remifentanil (0.2–0.75 µg/kg/h); lung-protective ventilation (low tidal volume, PEEP ≥5 cm H2O, driving pressure <16 cm H2O); multimodal analgesia with remifentanil infusion, sufentanil boluses (max 1 µg/kg ABW), 1 g metamizole, and parasternal wound infiltration (20 mL ropivacaine 7.5 mg/mL); PONV prophylaxis with dexamethasone (4–8 mg) and ondansetron (4 mg); recruitment maneuver after CPB; target core temperature ≥36 °C; and on-table extubation (OTE) in the OR immediately following surgery. Postoperative: early respiratory training, oral fluid/water ice within 6 h after extubation, full diet on day 1, early mobilization within 6 h, multimodal opioid-sparing analgesia, nonpharmacological delirium prevention, and early removal of chest tubes and catheters.

C

Comparator

Conventional perioperative standard care with delayed extubation in the ICU. Anesthesia induction with sufentanil (1 µg/kg), propofol (1–2 mg/kg), and rocuronium (1 mg/kg); maintenance with sevoflurane and intravenous infusion of sufentanil (1 µg/kg/h); sedation with propofol (3 mg/kg/h) during transfer and until extubation in the ICU.

O

Outcome

Postoperative length of stay, including duration of intensive care (LOS ICU), intermediate care (LOS IMC), and postoperative hospital stay (LOS hospital).surrogate

Main Result

Absolute Event Rate: 9% vs 11%

p-value: p=0.028

Implementing a comprehensive Enhanced Recovery After Cardiac Surgery (ERAS) protocol incorporating on-table extubation in low-risk elective coronary bypass and aortic valve replacement surgery is safe and significantly reduces ICU and hospital length of stay, catecholamine duration, delirium, and nosocomial infections.

Limitations

Before-after study design comparing a prospective cohort with a retrospective control group
Single-center study limiting generalizability
Non-randomized design with potential for selection bias
Patient satisfaction questionnaire was only evaluated in the RERACS group and not established in the retrospective control group
Before-after study design comparing the first prospective RERACS patients to a retrospective standard care cohort
Single-center study, which does not allow for generalization
Non-randomized design, meaning selection bias cannot be ruled out
Postoperative evaluation of patient satisfaction was only performed in the RERACS group and not in the retrospective control group

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Implication

Should not yet change practice with ERAS and on-table extubation; leaves open confirmation in randomized cardiac surgery trials.

Abstract

Background/Objectives: Enhanced recovery after surgery (ERAS) protocols aim to improve clinical outcomes, shorten hospital length of stay (LOS), and reduce costs through a multidisciplinary perioperative approach. Although introduced in colorectal surgery, they are less established in cardiac surgery, especially in combination with on-table extubation (OTE). This study evaluates the impact of a novel ERAS concept with OTE (RERACS) in elective aortic-valve-replacement and coronary bypass surgery. Methods: In a monocentric study, we compared a prospective RERACS-group (n = 114) to a retrospective control group (n = 119) (TRIAL Registration (DRKS00031402). The RERACS concept contained multiple perioperative treatment measures such as respiratory training, short fasting, and OTE. The control group received standard care. Results: Primary endpoint: postoperative LOS. Secondary measurements: length of postoperative vasoactive drug support, duration of mechanical ventilation, complication rate, and patient satisfaction on the second postoperative day. RERACS patients showed significantly shorter postoperative length of stay (ICU: 40 ± 34 h vs. 56 ± 51 h, p = 0.005; hospital: 9 ± 4 d vs. 11 ± 6 d, p = 0.028), lower nosocomial infection rates (24% vs. 40%), fewer cases of postoperative cognitive dysfunction ((subsyndromal) delirium 40% vs. 57%), reduced nausea and vomiting (14.9% vs. 32.8%), and faster weaning from catecholamines (22 ± 30 h vs. 42 ± 48 h, p < 0.001), as well as high patient satisfaction. Conclusions: Our study indicated that an ERAS concept with OTE is safe and associated with faster and improved recovery, including lower catecholamine requirements, reduced LOS, and high patient satisfaction in low-risk cardiac surgery.

Discussion

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Cite This Study

Werner et al. (2025) conducted a cohort in Elective coronary artery bypass surgery or aortic valve replacement surgery (n=233). Enhanced Recovery After Cardiac Surgery protocol with on-table extubation (RERACS) vs. Retrospective standard perioperative care with delayed extubation in the ICU was evaluated on Postoperative hospital length of stay (days) (p=0.028). Implementing an ERAS protocol with on-table extubation reduced postoperative ICU stay and hospital length of stay compared to standard care.

synapsesocial.com/papers/6a8c26d7039371f2a3898775 https://doi.org/10.3390/jcm14020352

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Effects of Implementing an Enhanced Recovery After Cardiac Surgery Protocol with On-Table Extubation on Patient Outcome and Satisfaction—A Before–After Study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Effects of Implementing an Enhanced Recovery After Cardiac Surgery Protocol with On-Table Extubation on Patient Outcome and Satisfaction—A Before–After Study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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