Overview of enhanced recovery after cardiothoracic surgery

INTRODUCTION — 

Enhanced recovery after surgery (ERAS) refers to multimodal multidisciplinary approaches that standardize perioperative care to minimize responses to surgical stress and postoperative pain, expedite recovery, decrease hospital length of stay, reduce complications, and improve outcomes following elective procedures [1]. Key components of enhanced recovery after cardiac surgery (ERACS) and enhanced recovery after thoracic surgery (ERATS) throughout the perioperative period are discussed in this topic.

Other topics discuss ERAS management and protocols for other types of major surgery such as gastrointestinal, orthopedic, urologic, and gynecologic surgical procedures. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)" and "Enhanced recovery after gynecologic surgery: Components and implementation".)

Routine preoperative management before cardiac surgery is discussed separately. (See "Overview of preoperative evaluation and management for cardiac surgery in adults".)

Routine postoperative management in the intensive care unit following cardiac surgical procedures is discussed separately. (See "Postoperative care after cardiac surgery".)

PREOPERATIVE STRATEGIES — 

Key components of enhanced recovery protocols for cardiac surgery (ERACS) or for thoracic surgery (ERATS) during the preoperative period include elements that begin weeks before surgery and elements in the immediate preoperative period [1-7].

General elements — General approaches to enhance cardiothoracic surgical care and outcomes include [1]:

●Use of a multidisciplinary approach – A multidisciplinary team with a dedicated coordinator serves to facilitate program implementation.

●Shared decision-making – Enhanced patient engagement through shared decision-making fosters patient education and helps establish realistic expectations.

●Routine evaluation of perioperative protocols and outcomes – Routine auditing and evaluation of the perioperative process are performed to assess compliance with program components and effects on clinical outcomes.

Elements that begin weeks before elective surgery

Preoperative screening and risk assessment — Preoperative screening and risk assessment (including identification and assessment of frailty, diabetes mellitus, hypoalbuminemia, elevated urine albumin-to-creatinine ratio, obstructive sleep apnea, chronic pain and substance use) is important to determine whether the patient is in optimal condition for surgery and to inform perioperative management [1]. The approach to preoperative evaluation is discussed further in separate topics. (See "Overview of preoperative evaluation and management for cardiac surgery in adults" and "Estimating the risk of valvular procedures" and "Preoperative physiologic pulmonary evaluation for lung resection".)

Anemia management — Anemia is common in both cardiac and thoracic surgical patients and is a risk factor for red blood cell transfusion and adverse outcomes [8,9]. Reversible causes should be diagnosed at least two to eight weeks prior to elective surgical procedures so that there is adequate time for appropriate interventions (eg, iron therapy and/or erythropoietin) to minimize perioperative transfusion of red blood cells, as noted in the algorithm and discussed in separate topics (algorithm 1) [8,9]. (See "Overview of preoperative evaluation and management for cardiac surgery in adults", section on 'Anemia' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)

Smoking cessation — Many patients undergoing pulmonary resection for lung cancer or cardiac surgery are current smokers. Patients who smoke are strongly encouraged to stop smoking preoperatively. Ideally, smokers quit at least four weeks before cardiothoracic surgery, but even brief preoperative abstinence (such as not smoking the morning of surgery) has benefits [9-11]. Smoking cessation reduces the risk of postoperative complications after cardiothoracic surgery, particularly before procedures such as pulmonary resection that require one lung ventilation as well as loss of lung tissue. Furthermore, smoking cessation may decrease long-term mortality after pulmonary resection [12]. (See "Smoking or vaping: Perioperative management", section on 'Rationale'.)

Strategies for smoking cessation in the preoperative setting are discussed in other topics. (See "Smoking or vaping: Perioperative management", section on 'Treatment of smoking in the perioperative period' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

Prehabilitation for selected patients — Selected patients (eg, those with frailty, malnutrition, poor functional capacity, and/or poor pulmonary function) may benefit from multicomponent prehabilitation to optimize their condition before elective cardiothoracic surgery [1]. Details are discussed in a separate topic. (See "Overview of prehabilitation for surgical patients".)

Some prehabilitation programs include preoperative physical exercise for sedentary frail patients with poor functional capacity. This may include aerobic, resistance, flexibility, balance, and strength exercises, as well as inspiratory muscle training (IMT). Inclusion of IMT in the exercise program may be particularly important for patients with chronic obstructive pulmonary disease (COPD) or lung cancer [13-23]. Systematic reviews of the efficacy of preoperative physical exercise and/or respiratory training before major thoracic or cardiac surgical procedures have reported the following improvements, although substantial heterogeneity was noted among studies:

●Thoracic surgery – Small randomized trials have found that preoperative exercise training is beneficial in patients undergoing lung cancer resection. A 2022 systematic review including 10 randomized trials with a total of 636 participants reported postoperative outcomes after preoperative exercise training that included supervised or unsupervised aerobic, resistance, IMT, or any combination of these types of training before open or video-assisted resection of non-small cell lung cancer [13]. The investigators noted reduced risk of developing postoperative pulmonary complications (PPCs) (risk ratio [RR] 0.45, 95% CI 0.33-0.61) and reduced postoperative length of stay (LOS) (-2.24 days, 95 CI -3.64 to -0.85 days). Exercise training also improved preoperative exercise capacity (measured by peak oxygen consumption) but had little or no effect on lung function (measured by forced expiratory volume in one second). Similar results were noted in older systematic reviews [14-16].

●Cardiovascular surgery – Small studies in patients undergoing cardiovascular surgery suggest that prehabilitation efforts are feasible and safe, although heterogenous interventions and inconsistent results limit conclusions regarding clinically important benefits. A 2019 systematic review of nonrandomized studies before cardiac surgery (seven studies) or vascular surgery (two studies) noted that preoperative exercise programs improved objective physical functioning and subjective measurements of quality of life compared with controls [17]. A 2019 network meta-analyses noted that evidence of benefit was strongest for use of IMT in prehabilitation efforts [18]. A 2023 randomized trial in 91 patients noted similar results for changes in maximal inspiratory pressure [24].

Elements in the immediate preoperative period

Limit fasting — Fasting guidelines have been established by international anesthesia societies (table 1), as discussed separately. (See "Preoperative fasting in adults".)

For patients at low risk for complications (ie, patients without diabetes mellitus and without high aspiration risk), clear fluids (eg, apple juice or sports electrolyte drink) are encouraged up until two hours before surgery, similar to enhanced recovery after surgery (ERAS) protocols for abdominal and other types of surgery. In nondiabetics, administration of a carbohydrate-containing clear fluid reduces postoperative insulin resistance. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative fasting'.)

Preoperative medication management

●Medications affecting bleeding risk – Since major cardiac and thoracic surgical procedures typically involve significant blood loss, it is particularly important to address the risk/benefit of antithrombotic therapies the patient has been receiving and to address reversible causes of abnormalities noted on tests of coagulation or platelet function, as discussed in separate topics. (See "Overview of preoperative evaluation and management for cardiac surgery in adults", section on 'Medications affecting hemostasis' and "Preoperative assessment of bleeding risk".)

●Preemptive analgesic medications

•Acetaminophen for both cardiac and thoracic surgical procedures – Oral acetaminophen 1 g is typically administered at least two hours preoperatively if there are no contraindications [1,3,4,6,7]. Intravenous (IV) acetaminophen 1 g may be administered after induction of anesthesia only if the patient did not receive preoperative acetaminophen. (See 'Cardiac surgery' below.)

•Cyclooxygenase (COX)-2 specific inhibitor for thoracic surgical procedures – For thoracic surgical patients without contraindications, an oral COX-2 inhibitor such as celecoxib 400 mg may be administered at least two hours preoperatively [5,9]. For most patients with established cardiovascular disease, we avoid use of oral nonselective nonsteroidal anti-inflammatory drugs (NSAIDS) or COX-2 specific inhibitors and use other medications to control pain, as discussed separately. (See "NSAIDs: Adverse cardiovascular effects", section on 'Our approach'.)

•Minimize or avoid benzodiazepine premedication – Similar to protocols for enhanced recovery after other types of major surgery, benzodiazepine use is limited or completely eliminated due to increased risk of delirium and cognitive dysfunction, oversedation, and upper airway obstruction [25-31]. Details are discussed in a separate topic. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative medications'.)

INTRAOPERATIVE MANAGEMENT — 

Key components for enhanced recovery after cardiac surgery (ERACS) or thoracic surgery (ERATS) during the intraoperative period include the use of minimally invasive surgical techniques for selected patients, maintenance of normovolemia and normothermia, prevention of nausea and vomiting, and planning for early extubation [2-4,6,9,32].

Use of minimally invasive surgical procedures — Minimally invasive surgical techniques are used for selected patients since these procedures typically involve less surgical trauma and postoperative pain, thereby potentially enhancing patient satisfaction and allowing more rapid recovery. Patient selection, procedural details, limitations (including a more restrictive operative field), and outcomes are discussed in other topics:

●Cardiac surgery – Approaches to selection of an open, minimally invasive, or transcatheter procedure for cardiac valve repair/replacement or for revascularization depends on many factors, as reviewed in separate topics:

•(See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use".)

•(See "Minimally invasive aortic and mitral valve surgery".)

•(See "Choice of intervention for severe calcific aortic stenosis".)

•(See "Chronic primary mitral regurgitation: Choice of intervention".)

•(See "Chronic secondary mitral regurgitation: Intervention".)

•(See "Tricuspid regurgitation: Management and prognosis".)

•(See "Tricuspid regurgitation: Management and prognosis", section on 'Role of heart valve team'.)

●Thoracic surgery – A minimally invasive technique such as video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracic surgery (RATS) rather than open thoracotomy is selected for many thoracic surgical procedures [9]. (See "Overview of minimally invasive thoracic surgery" and "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

Selection and dosing of anesthetic agents

Cardiac surgery — Maintenance techniques for patients undergoing cardiac surgery are described in a separate topic (see "Anesthesia for cardiac surgery: General principles", section on 'Maintenance techniques'). For ERACS protocols, anesthetic agents and dosing schemes that allow for possible early extubation are selected (see 'Early extubation' below):

●Volatile inhalation anesthetic – General anesthesia is maintained primarily with a volatile anesthetic inhalation agent (eg, sevoflurane, isoflurane). Use of raw or processed electroencephalography (EEG) such as the bispectral index (BIS) has been suggested as a supplemental monitor to appropriately dose anesthetic agents, in addition to monitoring age-adjusted end-tidal minimum alveolar concentration (MAC) (table 2). Monitoring of anesthetic depth is discussed in other topics. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Avoid excessive depth during general anesthesia' and "Management of cardiopulmonary bypass", section on 'Anesthetic depth'.)

●Analgesic agents

•Short-acting opioids – Limited doses of a shorter-acting synthetic opioid are a component of ERACS protocols. Examples include:

-Fentanyl with a total of <1 mg administered during induction and maintenance of anesthesia [32,33].

-Sufentanil with an infusion at 0.2 to 0.3 mcg/kg per hour that is discontinued at the time of chest closure [31,34].

-Remifentanil may be selected because of its rapid onset and offset. In one study, remifentanil was infused at 0.2 to 0.3 mcg/kg per minute throughout the operation and continued at a lower dose (0.1 to 0.15 mcg/kg per minute) to supplement the propofol infusion during patient transfer to the intensive care unit (ICU) [34].

We avoid higher doses of intraoperative opioids for patients participating in ERACS protocols [1,3,4,6,7]. Although high opioid doses may be selected for patients who will likely remain endotracheally intubated for several postoperative hours, this technique is becoming less common and is not appropriate when early extubation is planned [35]. (See "Anesthesia for cardiac surgery: General principles", section on 'Higher-dose opioid technique'.)

•Nonopioid analgesic agents

-Acetaminophen – If acetaminophen was not administered in the preoperative period, then an intraoperative age-adjusted dose of intravenous (IV) acetaminophen is typically administered near the end of the cardiac surgical procedure (table 3) [1,3,4,6,7].

-Dexmedetomidine – Intraoperative and/or postoperative dexmedetomidine is often a component of an ERACS protocol. At our institution, a dexmedetomidine infusion 0.3 to 0.7 mcg/kg per minute is typically started immediately after induction of anesthesia [36]. In some centers, dexmedetomidine may be continued in lower doses (eg, 0.1 to 0.2 mcg/kg per minute) as the sole sedative agent during transport from the operating room (OR) to the ICU. (See 'Specific strategies after cardiac surgery' below.)

-Ketamine – Alternatives to dexmedetomidine infusion include a ketamine infusion (eg, 10 to 15 mg/hour) beginning immediately after induction of anesthesia. Infusion may be discontinued before patient transport to the ICU or may be continued to serve as an adjunct to opioid-based pain management in the ICU [36]. (See 'Specific strategies after cardiac surgery' below.)

●Anesthetic agents that are minimized or avoided – We agree with recommendations from the Perioperative Neurotoxicity Working Group, which suggest minimizing or avoiding the use of benzodiazepines, anticholinergics (particularly scopolamine), diphenhydramine, metoclopramide, meperidine, and agents that may cause serotonin syndrome, to decrease risk for postoperative neurocognitive disorders including delirium [37,38]. Further discussion of the potential adverse effects of these agents is available in a separate topic. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)

●Dosing of neuromuscular blocking agents (NMBAs) – Neuromuscular blockade is typically maintained throughout the surgical procedure, with dosing guided by a peripheral nerve stimulator (PNS) [39]. Complete paralysis (with absence of twitches generated by the PNS) may increase risk of intraoperative awareness. (See "Management of cardiopulmonary bypass", section on 'Neuromuscular blocking agents' and "Accidental awareness during general anesthesia", section on 'Neuromuscular blockade'.)

For selected patients participating in an ERACS protocol, quantitative assessment with a PNS is performed at the end of the procedure before the patient leaves the OR. The effects of the NMBA are fully reversed for patients who will be extubated in the OR or shortly after arrival in the ICU [29].

Thoracic surgery — Similar to protocols for enhanced recovery after other types of major noncardiac surgery, short-acting IV and/or inhalation anesthetic agents, as well as short-acting NMBAs are typically selected to facilitate early emergence and extubation. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Anesthetic techniques'.)

Fluid and hemodynamic management

Cardiac surgery — Before and after cardiopulmonary bypass (CPB), the use of a restrictive zero-balance fluid management strategy aids in avoiding excessive fluid administration (see "Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy'). This is necessary because hemodilution occurs during CPB, due to the mixing of crystalloid in the CPB circuit prime (up to 1.5 liters of crystalloid) with the patient's blood volume.

Details of fluid and hemodynamic management are discussed in separate topics:

●(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass fluid management'.)

●(See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass", section on 'Avoid excessive fluid administration'.)

●(See "Intraoperative problems after cardiopulmonary bypass", section on 'Cardiovascular problems'.)

Blood management strategies during cardiac and surgery are discussed in separate topics. (See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass" and "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)

Thoracic surgery — A "moderate" goal-directed fluid management strategy is used to maintain normovolemia (see "Intraoperative fluid management", section on 'Goal-directed fluid therapy'), rather than a restrictive strategy or a liberal fluid management strategy. While the fluid regimen should be individualized to optimize cardiac output and O₂ delivery, excessive fluid administration (ie, >3 L in the 24 hours of the perioperative period) is avoided. Details of fluid and hemodynamic management are explained in a separate topic. (See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)

Blood management strategies to avoid or minimize the need for blood transfusion during thoracic and other major surgical cases are discussed separately. (See "Perioperative blood management: Strategies to minimize transfusions".)

Prevention and treatment of acute kidney injury — Acute kidney injury is common after cardiac surgery. Measures to screen for, prevent, and treat acute kidney injury after cardiac surgery are discussed in separate topics:

●(See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Chronic kidney disease and renal risk mitigation'.)

●(See "Postoperative complications among patients undergoing cardiac surgery", section on 'Kidney dysfunction'.)

●(See "Management of special populations during cardiac surgery with cardiopulmonary bypass".)

Lung protective ventilation — A lung protective ventilation strategy is used in all cardiothoracic surgical patients, during periods in which one lung or both lungs are ventilated [9,40,41]. Details regarding rationale and strategies for lung protective ventilation are discussed in separate topics:

●(See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

●(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass ventilation strategies'.)

●(See "Intraoperative one-lung ventilation", section on 'Lung-protective ventilation strategies during OLV'.)

Temperature management

●Cardiac surgery with CPB – Oropharyngeal and core body temperatures are monitored to maintain normothermia (≥35.5°C) during the prebypass and postbypass periods [2-4]. Both hyperthermia and hypothermia are avoided. Hyperthermia during the rewarming phase of CPB may increase the risk for postoperative cerebral dysfunction, surgical site infection, and acute kidney injury [42-44]. Hypothermia with temperature ≤35.5°C may exacerbate coagulopathy. Specific strategies for temperature management during and after CPB are discussed separately.

•(See "Management of cardiopulmonary bypass", section on 'Management during rewarming and weaning'.)

•(See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass", section on 'Maintenance of normothermia'.)

●Thoracic or cardiac surgery without CPB – Temperature is maintained near normothermia (≥35.5°C) throughout the perioperative period during cardiothoracic procedures that do not involve CPB [9]. General strategies for managing perioperative normothermia are discussed separately. (See "Perioperative temperature management".)

Nausea and vomiting prophylaxis — Proactive prevention of postoperative nausea and vomiting (PONV) is emphasized in both ERACS [4,32,45], and ERATS protocols [9]. As an example, our ERACS protocol calls for administration of IV dexamethasone 4 mg at the beginning of the case (typically after induction but before surgical incision), and IV ondansetron 4 mg administered at the end of the case [46]. Hydrocortisone can be substituted for dexamethasone for patients with steroid dependence or adrenal insufficiency.

These agents are also routinely administered in ERATS protocols. For patients with a strong history of PONV, inhalation anesthetics are avoided. These and other specific strategies for prevention of PONV are discussed in a separate topic. (See "Postoperative nausea and vomiting", section on 'Our strategy'.)

In addition, we employ multimodal pain management strategies incorporating techniques and agents that minimize opioid dosing to decrease risk for PONV. (See 'Multimodal pain management strategies' below and "Postoperative nausea and vomiting", section on 'Preventive measures for all patients'.)

Early extubation

●Cardiac surgery – Extubation may occur in the OR, but typically occurs within six hours of arrival in the ICU. Details regarding weaning from mechanical ventilation and extubation are discussed separately. (See "Postoperative care after cardiac surgery", section on 'Management of mechanical ventilation'.)

●Thoracic surgery – Most patients are extubated in the OR at end of the thoracic surgical procedure as described in separate topics. (See "Anesthesia for open pulmonary resection", section on 'Emergence and postoperative airway management' and "Anesthesia for esophagectomy and other esophageal surgery", section on 'Emergence and extubation'.)

A few selected patients may need a period of postoperative controlled mechanical ventilation, particularly those with poor preoperative pulmonary function or those who required administration of large volumes of fluid or blood or following complex thoracic surgical procedures such as extensive pulmonary or esophageal resection.

POSTOPERATIVE STRATEGIES — 

Most patients undergoing cardiac surgery and many undergoing open thoracic surgery are in an intensive care unit (ICU) for at least the first 24 postoperative hours. Key postoperative components for enhanced recovery after cardiac (ERACS) or thoracic surgery (ERATS) include use of opioid-sparing multimodal analgesic techniques to achieve early extubation and removal of chest tubes and urinary catheter, early ambulation, and prevention of atrial fibrillation [2-4,6,9,45]. These factors facilitate shorter durations of stay in the ICU and hospital, as well as return to baseline physical and neurocognitive function [1].

Multimodal pain management strategies — A multimodal approach to pain management optimizes perioperative pain control while reducing reliance on opioid-based analgesia [1].

Importance of adequate analgesia — Adequate analgesia is necessary after cardiac or thoracic surgery to avoid the following complications (see "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management' and "Postoperative care after cardiac surgery", section on 'General considerations'):

●Pulmonary complications (eg, respiratory insufficiency due to splinting).

●Cardiovascular complications (eg, myocardial ischemia or arrhythmias due to increased sympathetic activity).

●Postoperative delirium – (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Postoperative prevention strategies'.)

●Chronic pain syndromes – Moderate to severe pain persisting through the third postoperative day is a risk factor for the development of persistent pain syndromes after thoracotomy or sternotomy [6,47-52].

Specific strategies after cardiac surgery — We agree with recommendations from professional societies regarding use of multimodal, opioid-sparing postoperative pain management techniques [1,3,4,6,7]. This includes judicious use of opioids, nonopioid systemic analgesic agents, and, in some centers, regional and local anesthetic techniques. Specific details are discussed in a separate topic. (See "Postoperative care after cardiac surgery", section on 'Analgesia'.)

Specific strategies after thoracic surgery — Thoracotomy incisions are associated with greater acute postoperative pain than most other major surgical procedures [5,49]. Although the pathogenesis of pain after thoracic surgery is complex, factors include a typically large thoracic surgical incision with muscle retraction, rib spreading which can result in injury to sternocostal and costovertebral joints and intercostal nerves, bronchial resection, and opening of the pleural space [53]. Thus, multiple nociceptive signals amplify pain transmission, which can cause central sensitization. Meta-analyses suggest that approximately one-third of patients who underwent thoracotomy are still experiencing pain twelve months later [47,51]. Some develop a chronic post-thoracotomy pain syndrome, often with a primary neuropathic component that becomes unresponsive to opioid medication [47,49].

We agree with professional society recommendations regarding the need for customized multimodal opioid-sparing strategies to effectively control postoperative pain [5,9]. Specific strategies include:

●Regional anesthetic techniques

•The most common technique is either thoracic epidural analgesia (TEA) or thoracic paravertebral block (TPVB) with continuous infusion of analgesics via a catheter. Details regarding catheter placement and efficacy are discussed in a separate topic. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia' and "Anesthesia for open pulmonary resection", section on 'Thoracic paravertebral block'.)

•Other regional nerve blocks include erector spinae block, serratus anterior plane block, pectoral nerve block, or intercostal nerve blocks [54]. Details are discussed in a separate topic. (See "Anesthesia for open pulmonary resection", section on 'Other regional anesthetic techniques'.)

●Nonopioid systemic analgesic agents – Minimizing opioids is an important component of multimodal analgesic strategies. Similar to pain management after other types of major surgery, systemically administered nonopioid analgesics that are typically used in ERATS protocols include combinations of acetaminophen plus a nonsteroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 specific inhibitor (in patients without contraindications) [5,9,55,56]. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Pharmacologic agents'.)

Other nonopioid analgesic agents include:

•Dexmedetomidine, an alpha-2 agonist with sedative and anesthetic-sparing properties, is sometimes administered as an infusion during the first 24 hours after cardiothoracic surgery. Dexmedetomidine has been associated with improved postoperative pain scores, and reduced opioid requirements and respiratory complications in this setting [5,9,57]. (See "Postoperative care after cardiac surgery", section on 'Nonopioid systemic analgesics'.)

•Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that is of uncertain benefit, but is used in subanesthetic doses in some ERATS protocols to reduce morphine consumption and improve early postoperative lung function, particularly in patients with opioid tolerance [5,9,58]. (See "Postoperative care after cardiac surgery", section on 'Nonopioid systemic analgesics' and "Anesthesia for open pulmonary resection", section on 'Opioid and nonopioid intravenous analgesics'.)

•Gabapentinoids are not used for most patients participating in enhanced recovery protocols. A retrospective cohort study in patients undergoing thoracic surgery noted that perioperative gabapentinoid administration was associated with an increased risk for postoperative pulmonary complications (odds ratio 1.14, 95% CI 1.11-1.28) [59].

●Judicious use of opioids – Limited administration of opioids, preferably using a patient-controlled analgesia (PCA) technique [5,9,49,60,61], may be necessary to provide effective analgesia, prevent splinting, and enable adequate spontaneous ventilation in the immediate postoperative period. However, opioid use is minimized in ERATS protocols to reduce risk of respiratory depression after thoracic surgery [61,62], particularly in older patients or those with preexisting pulmonary conditions such as chronic obstructive pulmonary disease. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Pharmacologic agents'.)

Postoperative nausea and vomiting (PONV) is another potential adverse side effect of any opioid, and must be promptly treated. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Management of nausea and vomiting'.)

Furthermore, a specific concern regarding opioid administration after a painful thoracic surgical procedure is the possible development of chronic opioid dependence. Persistent opioid use is associated with poor compliance with postoperative treatment, increased postoperative morbidity including cardiovascular risk, and decreased overall survival (particularly cancer-specific survival) [63].

Early postoperative mobilization — As with enhanced recovery after other major surgical procedures, early postoperative mobilization (ambulation and upper extremity exercise) is encouraged to hasten recovery and reduce the risk of postoperative pneumonia and venous thromboembolism [1]. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Early mobilization' and "Postoperative care after cardiac surgery", section on 'Mobility'.)

To facilitate early mobility after either cardiac or thoracic surgery, early extubation and early removal of chest tubes and urinary catheter are usually appropriate [9]. Of note, for many thoracic surgical procedures, a urinary catheter is not placed. In addition, some ERATS protocols specify that tamsulosin may be administered to male patients to encourage urinary flow.

Early enteral hydration and nutrition — As with other major surgical procedures, early resumption of an oral diet and hydration is optimal, ideally within a few hours after surgery (or shortly after tracheal extubation) [9]. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Early oral feeding' and "Postoperative care after cardiac surgery", section on 'Diet'.)

Prevention of atrial fibrillation

●Cardiac surgery – Postoperative atrial fibrillation (AF) occurs frequently after cardiac surgery (eg, in 15 to 40 percent of patients in the early postoperative period following coronary artery bypass graft surgery [CABG]). Our approach to prophylaxis against AF focuses on ensuring adequate serum potassium and magnesium levels and early use of a beta blocker (or other agent), as discussed in a separate topic. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation' and "Atrial fibrillation and flutter after cardiac surgery", section on 'Management of post-operative AF'.)

●Thoracic surgery – Postoperative AF is also common after thoracic surgery, occurring in 12 to 44 percent of patients, and is associated with increased risks for pulmonary complications, prolonged hospital length of stay, and mortality [9,64]. Prophylaxis against AF after thoracic surgery includes continuing chronically administered beta-blockers, ensuring adequate serum potassium and magnesium levels, and, in selected cases, administration of prophylactic medications for high-risk patients who are not taking beta-blockers (eg, preoperative diltiazem or postoperative amiodarone). Further discussion is available in a separate topic. (See "Overview of pulmonary resection", section on 'Preventive measures'.)

OUTCOMES

ERACS programs — Compared with conventional care, limited data regarding outcomes suggest that implementation of an enhanced recovery after cardiac surgery (ERACS) program is associated with reductions in time to postoperative extubation, less postoperative opioid administration, fewer blood transfusions, reduced length of stay in the intensive care unit (ICU) and hospital, and reduced costs [3,4,29,32,65-71].

A 2024 meta-analysis included 13 single-center trials with a total of 1704 patients undergoing cardiac surgery (850 patients participating in a variety of ERACS protocols and 854 in standard care groups) [71]. Protocols in the majority of the trials focused on goal-directed fluid therapy and multimodal opioid-sparing analgesia (see 'Multimodal pain management strategies' above and 'Fluid and hemodynamic management' above). Findings included [71]:

●In-hospital mortality rates were not significantly lower in the ERACS group compared to the standard care group (risk ratio [RR] 0.61, 95% CI 0.31-1.20).

●The ERACS group had shorter length of stay (LOS) in the ICU (standardized mean difference [SMD] = 0.57 day) and hospital (SMD -0.23 day).

●The ERACS group had lower rates of postoperative complications compared with the standard protocol (RR 0.60, 0.48-0.73), particularly reduction in stroke (RR 0.29, 95% CI 0.13-0.62).

An important issue in this meta-analysis was the substantial heterogeneity in specific aspects of individual ERACS protocols [71]. Challenges in determining efficacy of ERACS protocols include the fact that program goals and measured outcomes are typically institution-specific. This limits generalizability of published study results. Furthermore, the likelihood of achieving the goals of any ERACS program is associated with the degree of compliance with program components [29].

ERATS programs — Limited data from largely observational studies suggest improved postoperative outcomes after implementation of enhanced recovery after thoracic surgery (ERATS) protocols for pulmonary resection procedures including a reduction in opioid use, improved postoperative pain control, decreased length of hospital stay, and decreased costs [9,27,55,62,72-81]. Studies comparing the use of ERATS protocols for lung resection surgery with conventional care include:

●A 2021 systematic review and meta-analysis of 17 individual studies with 7098 participants noted lower overall morbidity in ERATS patients compared with control group patients (risk ratio [RR] 0.64, 95% CI 0.51-0.80), particularly rates of pulmonary (RR 0.43, 95% CI 0.31-0.60) and surgical complications (RR 0.46, 95% CI 0.25-0.83) [76]. Cardiovascular complications and in-hospital mortality were similar in the groups. Implementation of an ERATS protocol was also associated with a shorter hospital LOS (mean difference -2.17 days; 95% CI -2.98 to 1.36 days) [76]. Readmission rates were similar with ERATS and conventional care. The investigators noted marked heterogeneity among the studies.

●A subsequently published 2021 prospective study compared 169 patients undergoing pulmonary resection before implementation of an ERATS protocol with 126 patients after implementation [62]. The investigators noted increased use of minimally invasive surgery (62.7 versus 39.6 percent), reduced ICU utilization (21.4 versus 70.4 percent), and shorter hospital LOS (4.4 versus 3.2 days, 95% CI 0.3-2.0 days) after ERATS implementation. Also, improved early removal of chest tubes (54.8 versus 24.3 percent) and urinary catheters (65.1 versus 20.1 percent) by postoperative day one, improved success with ambulation at least three times on postoperative day one (54.8 versus 46.8 percent), and decreased opioid use (101 versus 82 daily oral morphine equivalents, 95% CI 1-36) were noted [62]. Furthermore, an overall decrease in the incidence of morbid events (delirium, atrial fibrillation, myocardial infarction, atelectasis, pneumothorax, pleural effusion, respiratory failure, air leak, renal failure, venous thromboembolism, blood transfusion, pneumonia, surgical site infection, urinary tract infection, and sepsis) and direct costs of hospitalization were noted.

Similar to ERACS programs (see 'ERACS programs' above), considerable heterogeneity among studies has been attributed to variability among different institutions and even among surgeons within the same hospital [72-74,76]. Positive effects of ERATS protocols for patients undergoing pulmonary resection are greatest when high compliance with all elements of the pathway is achieved, rather than implementing one or two elements in isolation [9,29,75,77-79].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Enhanced recovery after surgery".)

SUMMARY AND RECOMMENDATIONS

●Preoperative period – Strategies for enhanced recovery after cardiac surgery (ERACS) or thoracic surgery (ERATS) include a multidisciplinary approach and routine evaluation to assess compliance with protocol elements and effects on clinical outcomes. (See 'General elements' above and 'Outcomes' above.)

•Elements that begin weeks before surgery – Preoperative screening and risk assessment is important to determine whether the patient is in optimal condition.

-Anemia management – Preoperative treatment of reversible causes of anemia (algorithm 1), as discussed separately. (See "Overview of preoperative evaluation and management for cardiac surgery in adults", section on 'Anemia' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)

-Smoking cessation – Smoking cessation, as discussed separately. (See "Smoking or vaping: Perioperative management", section on 'Treatment of smoking in the perioperative period' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

-Prehabilitation – Prehabilitation for selected high-risk patients, as discussed separately. (See "Overview of prehabilitation for surgical patients".)

•Elements in the immediate preoperative period

-Limit fasting – Fasting guidelines established by international anesthesia societies are followed (table 1). For most patients, clear fluids (eg, apple juice or sports electrolyte drink) are encouraged up until two hours before surgery, similar to enhanced recovery protocols for other types of surgery. (See "Preoperative fasting in adults" and "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative fasting'.)

-Preoperative medication management

Medications affecting bleeding risk – Management of chronically administered medications affecting hemostasis are discussed in separate topics. (See "Overview of preoperative evaluation and management for cardiac surgery in adults", section on 'Medications affecting hemostasis' and "Preoperative assessment of bleeding risk".)

Preemptive analgesic medications – For cardiac or thoracic surgical patients, acetaminophen is typically administered in the preoperative period. For thoracic surgical patients without contraindications, a cyclooxygenase (COX)-2 specific inhibitor such as celecoxib is also typically administered. (See 'Multimodal pain management strategies' above.)

Avoidance or minimal use of benzodiazepines – (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative medications'.)

●Intraoperative period

•Use of minimally invasive surgical procedures for selected patients – Patient selection and procedural details are discussed in other topics:

-(See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use".)

-(See "Minimally invasive aortic and mitral valve surgery".)

-(See "Choice of intervention for severe calcific aortic stenosis".)

-(See "Chronic primary mitral regurgitation: Choice of intervention".)

-(See "Chronic secondary mitral regurgitation: Intervention".)

-(See "Tricuspid regurgitation: Management and prognosis".)

-(See "Tricuspid regurgitation: Management and prognosis", section on 'Role of heart valve team'.)

-(See "Overview of minimally invasive thoracic surgery".)

-(See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection".)

•Selection and dosing of anesthetic agents

-Cardiac surgery – Anesthetic agents and dosing schemes that allow for possible early extubation are selected. (See 'Cardiac surgery' above.)

-Thoracic surgery – Similar to ERAS protocols for noncardiac surgery, short-acting intravenous (IV) and/or inhalation anesthetic agents and neuromuscular blocking agents are selected. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Anesthetic techniques'.)

•Fluid and hemodynamic management

-Cardiac surgery – Use of a restrictive zero-balance fluid management strategy before and after cardiopulmonary bypass (CPB) aids in avoiding excessive fluid administration, as influenced by hemodilution due to crystalloid volume in the CPB circuit prime. Details are explained in separate topics:

(See "Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy'.)

(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass fluid management'.)

(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass fluid management'.)

(See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass", section on 'Avoid excessive fluid administration'.)

-Thoracic surgery – A "moderate" goal-directed fluid management strategy (rather than a restrictive or liberal fluid management strategy) is used to maintain normovolemia, as explained in separate topics:

(See "Intraoperative fluid management", section on 'Goal-directed fluid therapy'.)

(See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)

•Prevention and treatment of acute kidney injury after cardiac surgery – Measures are discussed in separate topics:

-(See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Chronic kidney disease and renal risk mitigation'.)

-(See "Postoperative complications among patients undergoing cardiac surgery", section on 'Kidney dysfunction'.)

-(See "Management of special populations during cardiac surgery with cardiopulmonary bypass".)

•Lung protective ventilation – Strategies for lung protective ventilation are discussed in separate topics:

-(See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

-(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass ventilation strategies'.)

-(See "Intraoperative one-lung ventilation", section on 'Lung-protective ventilation strategies during OLV'.)

•Temperature management – Strategies for maintaining temperature near normothermia (≥35.5°C) throughout the perioperative period during cardiothoracic procedures not involving CPB (and during the prebypass and postbypass periods during cardiac surgery with CPB) are discussed separately. (See "Perioperative temperature management".)

•Preventing postoperative nausea and vomiting (PONV) – Prophylaxis to prevent PONV is emphasized; strategies are discussed separately. (See "Postoperative nausea and vomiting", section on 'Our strategy'.)

•Early extubation

-Cardiac surgery – Extubation may occur in the operating room (OR), but typically occurs within six hours of arrival in the intensive care unit (ICU), as discussed separately. (See "Postoperative care after cardiac surgery", section on 'Management of mechanical ventilation'.)

-Thoracic surgery – Most patients are extubated in the OR at end of the procedure, as described in separate topics. (See "Anesthesia for open pulmonary resection", section on 'Emergence and postoperative airway management' and "Anesthesia for esophagectomy and other esophageal surgery", section on 'Emergence and extubation'.)

●Postoperative period

•Multimodal pain management – Multimodal opioid-sparing strategies are used to provide adequate analgesia while reducing reliance on opioid-based analgesia to prevent pulmonary and cardiovascular complications, delirium, and chronic pain syndromes.

-Cardiac surgery – Strategies include nonopioid systemic analgesic agents (eg, acetaminophen) and judicious use of opioids. In some centers, regional and local anesthetic techniques are also employed, as discussed separately. (See "Postoperative care after cardiac surgery", section on 'Analgesia'.)

-Thoracic surgery – Usual strategies include a neuraxial analgesic technique (thoracic epidural analgesia or thoracic paravertebral block) or other regional anesthetic techniques (eg, erector spinae, serratus anterior plane, pectoral nerve, intercostal nerve blocks), as discussed separately. (See "Anesthesia for open pulmonary resection", section on 'Regional anesthesia'.)

Nonopioid analgesics are also typically used (combinations of acetaminophen and a nonsteroidal anti-inflammatory or COX-2 inhibitor agent), similar to enhanced recovery after surgery (ERAS) protocols for noncardiac surgery. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Pharmacologic agents'.)

•Early postoperative mobilization – Early postoperative mobilization is encouraged, similar to ERAS protocols for noncardiac surgery. Early extubation and removal of chest tubes and urinary catheter facilitate mobility. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Early mobilization' and "Postoperative care after cardiac surgery", section on 'Mobility'.)

•Early enteral nutrition – Early resumption of an oral diet within a few hours after surgery (or shortly after extubation) is optimal, as with other ERAS protocols. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Early oral feeding' and "Postoperative care after cardiac surgery", section on 'Diet'.)

•Prevention of atrial fibrillation (AF)

-Cardiac surgery – Prophylaxis against AF after cardiac surgery typically includes early use of a beta blocker, as discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation' and "Atrial fibrillation and flutter after cardiac surgery", section on 'Management of post-operative AF'.)

-Thoracic surgery – Prophylaxis against AF after thoracic surgery includes continuing chronically administered beta-blockers, ensuring adequate magnesium levels, and administering prophylactic medications for selected patients at high risk who are not taking beta-blockers, as discussed separately. (See "Overview of pulmonary resection", section on 'Preventive measures'.)