nhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. 1 These programs aim to reduce complications and promote an earlier return to normal activities. 2,3 The ERAS protocols have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management in populations having noncardiac surgery. 4-6 Evidence-based ERAS protocols have been published across multiple surgical specialties. 1 In early studies, the ERAS approach showed promise in cardiac surgery (CS); however, evidence-based protocols have yet to emerge. 7 To address the need for evidence-based ERAS protocols, we formed a registered nonprofit organization (ERAS Cardiac Society) to use an evidence-driven process to develop recommendations for pathways to optimize patient care in CS contexts through collaborative discovery, analysis, expert consensus, and best practices. The ERAS Cardiac Society has a formal collaborative agreement with the ERAS Society. This article reports the first expert-consensus review of evidence-based CS ERAS practices. Methods We followed the 2011 Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, using a standardized algorithm that included experts, key questions, subject champions, systematic literature reviews, selection and appraisal of evidence quality, and development of clear consensus recommendations. 8 We minimized repetition of existing guidelines and consensus statements and focused on specific information in the framework of ERAS protocols.

Objectives To characterize operative outcomes for ascending aorta and arch replacement on a national scale and develop risk models for mortality and major morbidity. Background Contemporary outcomes for ascending aorta and arch replacement in North America are unknown. Methods We queried the Society of Thoracic Surgeons Database for patients undergoing ascending aorta (+/− root) +/− arch replacement from 2004 to 2009. The database captured 45,894 cases, including 12,702 root, 22,048 supracoronary ascending alone, 6,786 ascending+arch, and 4,358 root+arch. Baseline characteristics and clinical outcomes were analyzed. A parsimonious multivariable logistic regression model was constructed to predict risks of mortality and major morbidity. Results Operative mortality was 3.4% for elective and 15.4% for non-elective cases. A risk model for operative mortality [c-index 0.81] revealed a risk-adjusted odds ratio (OR) for death following emergent vs. elective operation of 5.9 [95% confidence interval (CI) 5.3, 6.6]. Among elective patients, end stage renal disease and re-operative status were the strongest predictors of mortality (adjusted OR 4.0 [95% CI 2.6, 6.4] and 2.3 [95% CI 1.9, 2.7] respectively, p<0.0001). Conclusions Current outcomes for ascending aorta and arch replacement in North America are excellent for elective repair; however, results deteriorate for non-elective status, suggesting that increased screening and/or lowering thresholds for elective intervention could potentially improve outcomes. The predictive models presented may serve clinicians in counseling patients.

Objective: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States.Methods: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre-and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.Results: Comparing the pre-(N ¼ 489) with the post-(N ¼ 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P <.01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P <.01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P <.05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P <.01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P ¼ not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.Conclusions: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.