Version May 2024
INTRODUCTION — Enhanced recovery after surgery (ERAS) refers to multimodal multidisciplinary approaches that standardize perioperative care to minimize surgical stress response and postoperative pain, expedite recovery, decrease hospital length of stay, reduce complications, and improve outcomes following elective procedures. This topic discusses management of elements of anesthetic and surgical management to facilitate enhanced recovery after cardiac surgery (ERACS).
A separate topic addresses anesthesia for enhanced recovery after thoracic surgery (ERATS). (See "Anesthetic management for enhanced recovery after thoracic surgery".)
Other topics discuss ERAS management and protocols for other types of major surgical procedures such as gastrointestinal (eg, colorectal surgery, liver resection, gastrectomy, pancreaticoduodenal surgery), urological (eg, radical nephrectomy and cystectomy), gynecological (eg, hysterectomy, gynecological oncological surgery), and orthopedic (eg, total joint replacement, complex spine surgery) surgery:
●(See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)
●(See "Enhanced recovery after colorectal surgery".)
●(See "Enhanced recovery after gynecologic surgery: Components and implementation".)
GOALS OF ENHANCED RECOVERY AFTER CARDIAC SURGERY — Enhanced recovery after surgery (ERAS) programs were initially designed to improve outcomes after colorectal surgery. These multidisciplinary interventions provide consistent care throughout the perioperative period with the aims of optimizing preoperative condition, preserving organ function, and hastening postoperative recovery and return to baseline physical and neurocognitive function [1]. Such standardized, evidence-based approaches minimize unjustified variability in care. (See "Enhanced recovery after colorectal surgery" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)
Similarly, protocols for enhanced recovery after cardiac surgery (ERACS) include standardized multidisciplinary approaches for care of patients undergoing elective cardiac procedures [2-7]. Specific goals include:
●Minimizing stress responses to surgery and anesthesia
●Using multimodal analgesic strategies to control postoperative pain
●Achieving early extubation
●Decreasing hospital length of stay
●Expediting recovery
●Reducing postoperative complications
●Improving clinical outcomes
PREOPERATIVE PERIOD
Prehabilitation efforts — Some patients may benefit from prehabilitation to achieve optimal condition before elective cardiac surgery (eg, those with frailty, malnutrition, cognitive dysfunction, or need for smoking cessation). Details are discussed in a separate topic. (See "Overview of prehabilitation for surgical patients".)
Preanesthetic consultation — Other aspects of a standard preanesthetic consultation include education of the patient and family regarding management of perioperative medications, planned use of multimodal analgesic techniques, and expectations for early extubation and postoperative recovery in an enhanced recovery after cardiac surgery (ERACS) program. (See "Preoperative evaluation for anesthesia for cardiac surgery" and 'Day of surgery' below and 'Postoperative management' below.)
It is particularly important to address abnormalities on tests of coagulation or platelet count or function, which should prompt evaluation for reversible causes such as chronically administered medications that affect hemostasis (eg, antiplatelet agents, parenteral or enteral anticoagulant agents). (See "Preoperative assessment of bleeding risk" and "Preoperative evaluation for anesthesia for cardiac surgery", section on 'Medications affecting hemostasis'.)
Anemia is common in cardiac surgical patients and it is particularly important to diagnose the cause and correct anemia to minimize perioperative transfusion of red blood cells, as noted in the Society of Cardiovascular Anesthesiologists and other professional society guidelines (algorithm 1) [8]. (See "Preoperative evaluation for anesthesia for cardiac surgery", section on 'Anemia'.)
DAY OF SURGERY
Multimodal pain management — The Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Society recommends perioperative multimodal, opioid-sparing age-adjusted pain management planning as an essential component of any comprehensive program, similar to enhanced recovery after other major surgical procedures [2,9].
We limit use of opioids, as described separately. (See "Postoperative care after cardiac surgery", section on 'Opioids'.).
We start with a low dose of acetaminophen (ie, 650 to 1000 mg), with the first dose typically administered in the preoperative period, then every six to eight hours in the postoperative period for five days, and subsequently as needed. (See "Postoperative care after cardiac surgery", section on 'Nonopioid systemic analgesics'.).
We reserve scheduled administration of gabapentinoids (eg, gabapentin, pregabalin) during the perioperative period for selected patients to limit opioid exposure. Dosing adjustments are based on age, gender, and renal function, as outlined in the table (table 1). The first dose of gabapentin is administered approximately one to two hours before surgery, and the next dose is administered on the evening of surgery. Some institutions administer only a single preoperative dose [10]. We do not administer gabapentin to patients >70 years of age, or to those with glomerular filtration rate (GFR) <30 mL/min. Notably, use of gabapentinoids necessitates appropriate respiratory monitoring due to increased risk of somnolence associated with their use. Data for gabapentin use in cardiac surgical patients are limited. Some evidence suggests that gabapentin reduces opioid use and improves pain scores in these patients [10-13], while others show no reduction in perioperative opioid consumption or pain scores [14,15]. Although some ERACS programs in the United States administer both gabapentin and acetaminophen, there are no specific data regarding the efficacy of this combination in cardiac surgical patients [16-19]. Also, there are adverse side effects of gabapentinoids that include sedation, dizziness, and visual disturbances [10,15,20,21]. Other agents are used in some centers include dexmedetomidine and ketamine, as described separately. (See "Postoperative care after cardiac surgery", section on 'Nonopioid systemic analgesics'.)
Neuraxial and regional techniques may be employed in selected patients, as described separately. (See "Postoperative care after cardiac surgery", section on 'Neuraxial and regional anesthetic techniques'.)
Management of chronically administered medications — Perioperative management of chronically administered medications (eg, cardiovascular mediations, antiplatelet agents or anticoagulant agents affecting hemostasis) is addressed in a separate topic. (See "Preoperative evaluation for anesthesia for cardiac surgery", section on 'Management of preoperative medications'.)
Minimize use of benzodiazepine premedication — Perioperative use of benzodiazepines is minimized due to adverse side effects that include increased risk of delirium, particularly in older adults [22,23]. Extra caution (ie, careful titration of smaller doses) is warranted for many cardiac surgical patients such as those with critical aortic stenosis or severe ventricular dysfunction, or in patients >80 years old. ERACS protocols in many centers recommend either complete elimination or limited use (1 to 5 mg intravenous or up to 7.5 mg orally) of any benzodiazepine [24-27].
Preoperative consumption of liquids — We follow fasting guidelines established by international anesthesia societies (table 2). Some centers encourage consumption of clear liquids until two to four hours before general anesthesia. (See "Preoperative fasting in adults" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative considerations'.)
INTRAOPERATIVE MANAGEMENT
Selection and dosing of anesthetic agents — General considerations regarding selection of anesthetic agents and techniques for induction and maintenance of general anesthesia are described separately. (See "Anesthesia for cardiac surgery: General principles", section on 'Balanced technique' and "Anesthesia for cardiac surgery: General principles", section on 'Maintenance techniques'.)
For patients managed according to an enhanced recovery after cardiac surgery (ERACS) protocol, multimodal opioid-sparing perioperative pain management strategies begin during the preoperative phase (see 'Multimodal pain management' above), and continue into the intraoperative phase. These may include:
●Short-acting opioids – We use limited doses of shorter-acting synthetic opioids (eg, fentanyl with a total of <1 mg administered during the case) during induction and maintenance of anesthesia) [28]. In some institutions, sufentanil is selected due to its more predictable context-sensitive half-life; typically, an infusion at 0.2 to 0.3 mcg/kg per hour is started immediately after anesthetic induction and discontinued at the time of chest closure [27,29]. In other institutions, remifentanil is selected because of its rapid onset and offset. In one study, a remifentanil infusion was administered 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) as a supplement to the propofol infusion administered during patient transfer to the intensive care unit (ICU) [29].
We avoid high doses of intraoperative opioids. High-dose opioid anesthetic induction techniques may lead to chest wall rigidity, as well as prolonged respiratory depression and need for mechanical ventilation, increased ICU stays, delayed recovery, and potential for postoperative complications [30,31]. Traditionally, some centers used relatively high doses of a synthetic opioid (eg, fentanyl 10 to 25 mcg/kg) for selected patients who would remain endotracheally intubated for several postoperative hours, because this technique results in minimal direct myocardial depressant effect and only a small decrease in blood pressure (see "Anesthesia for cardiac surgery: General principles", section on 'Higher-dose opioid technique'). However, this technique is becoming less common, in part because of recognition of inappropriate opioid use in the United States [32]. Also, we avoid administration of long-acting opioids such as morphine during the intraoperative and postoperative periods. (See "Postoperative care after cardiac surgery", section on 'Opioids' and "Opioid use disorder: Epidemiology, clinical features, health consequences, screening, and assessment".)
●Nonopioid analgesics
•Dexmedetomidine – We administer dexmedetomidine to patients participating in our ERACS program, beginning immediately after induction of anesthesia with an infusion at 0.3 to 0.7 mcg/kg per minute [33]. In some centers, the dexmedetomidine infusion is 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 to the ICU.
•Ketamine – A ketamine infusion at 10 to 15 mg/hour (or 0.1 to 0.2 mg/kg/hour) started immediately after induction of anesthesia is an alternative analgesic option. At these doses, ketamine may be discontinued either before patient transport to the ICU, or may be continued as a viable adjunct to opioid-based pain management in the ICU [33].
•Acetaminophen – If acetaminophen was not previously administered in the preoperative period, then an intraoperative age-adjusted dose of intravenous (IV) acetaminophen is administered near the end of the cardiac surgical procedure (table 3). (See 'Multimodal pain management' above.)
Selection and dosing of neuromuscular blocking agents — A neuromuscular blocking agent (NMBA) is employed to facilitate endotracheal intubation after induction of anesthesia. (See "Anesthesia for cardiac surgery: General principles", section on 'Induction techniques'.)
Neuromuscular blockade is typically continued throughout the surgical procedure, with dosing guided by a peripheral nerve stimulator (PNS) [34]. Complete paralysis with absence of twitches on the peripheral nerve stimulator 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 patients participating in an ERACS protocol, we also perform quantitative assessment with a PNS at the end of the procedure before the patient leaves the operating room. We fully reverse the NMBA for patients who will be extubated in the operating room or shortly after arrival in the intensive care unit (ICU) [25].
Preservation of organ function
Neurocognitive function — We agree with recommendations from the Perioperative Neurotoxicity Working Group, which suggest minimizing or avoiding use of benzodiazepines, anticholinergics (particularly scopolamine), diphenhydramine, metoclopramide, opioids (particularly meperidine), and agents that may cause serotonin syndrome, in order to decrease risk for postoperative delirium and other types of perioperative neurocognitive disorder (PND) [35,36]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
Use of raw or processed electroencephalography (EEG) such as the bispectral index (BIS) has been suggested as a supplemental monitor of age-adjusted end-tidal minimum alveolar concentration (MAC) fraction (table 4), in order to appropriately dose anesthetic agents, avoid excessive anesthetic depth, and minimize risk of PND [35,37]. However, deep anesthesia with low BIS value has not been consistently associated with delirium or other adverse outcomes in studies that included cardiac surgical patients [38-41]. Limited data in cardiac and noncardiac surgical patients suggest that cerebral oximetry (ie, near infrared spectroscopy [NIRS] technology) may be useful to detect abnormalities in autoregulation of cerebral blood flow [42-45]. Using EEG-based anesthetic titration together with cerebral oximetry monitoring may be optimal [42], and large randomized trials are in progress to determine whether such dual monitoring techniques are effective [46,47]. (See 'Hemodynamic management' below and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Avoid excessive depth during general anesthesia'.)
Use of cerebral near-infrared spectroscopy (NIRS) during cardiac surgery has been suggested to facilitate identification of patients who may have prolonged length of stay in the ICU based on preoperative cerebral oximetry values and intraoperative values indexed to an individual’s preinduction baseline [48]. However, there is scant evidence that perioperative use of NIRS can reduce mortality or organ-specific morbidity after cardiac surgery.
Pulmonary function — We use an intraoperative lung-protective ventilation strategy in the prebypass and postbypass period (with low tidal volume [TV], low driving pressure, and positive end-expiratory pressure [PEEP]) to potentially reduce the incidence of pulmonary complications. Details are discussed in separate topics. (See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass ventilation strategies' and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)
We typically transition the patient to pressure support mechanical ventilation following chest closure to facilitate early endotracheal extubation (either in the operating room within six hours later in the ICU).
Fluid management — Prior to cardiopulmonary bypass (CPB), fluid administration (usually with a balanced crystalloid solution rather than a colloid solution) is typically restricted to the small volumes necessary to administer IV medications because initiation of CPB results in significant hemodilution as the CPB circuit prime (up to 1.5 liters of crystalloid) mixes with the patient's blood volume. Excessive fluid administration and the resulting hemodilution are avoided to reduce risk for adverse effects such as coagulopathy and increased use of blood products, as well as pulmonary and gastrointestinal edema, heart failure, acute kidney injury, postoperative weight gain, poor tissue healing, delirium, and longer durations of controlled mechanical ventilation and hospital stay [49,50]. (See "Intraoperative fluid management", section on 'Hypervolemia'.)
For these reasons, we employ a zero-balance fluid management strategy during the prebypass and postbypass periods, with the aim of maintaining central euvolemia while minimizing excess salt and water [51-53]. When hypovolemia is suspected as a result of dehydration or blood loss, we administer an IV fluid challenge (typically a bolus of 250 mL) to assess intravascular fluid responsiveness. (See "Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy'.)
Guidelines developed for goal-directed fluid therapy are used by some centers [54-56] (see "Intraoperative fluid management", section on 'Goal-directed fluid therapy'). Several monitoring devices using “dynamic” parameters of fluid responsiveness are available to assess intravascular volume status by determining whether a fluid bolus (typically 100 to 250 mL) delivered over 5 to 10 minutes will increase a measure of intravascular volume by approximately 10 percent [57]. We use transesophageal echocardiography (TEE), particularly the transgastric midpapillary short-axis view, for qualitative visual assessment of left ventricular (LV) cavity size. Underfilling of the left ventricle caused by acute hypovolemia is recognized in a patient with decreased end-diastolic and end-systolic LV cavity dimensions (movie 1). Also, quantitative measurements of the internal diameter or cross-sectional area of the LV at end-diastole can be made (image 1 and image 2 and table 5) [58,59]. (See "Intraoperative transesophageal echocardiography for noncardiac surgery", section on 'Assessment of left ventricular volume'.)
Measurement or continuous monitoring of cardiac output (CO) and stroke volume (SV) with a pulmonary artery catheter (PAC) is often used to assess volume status or fluid responsiveness. Other technologies (eg, esophageal Doppler-derived CO [60,61]) may be used if transesophageal echocardiography is not employed during the operation. In addition, several devices can be used to assess variations in the arterial pressure waveform occurring during respiration (eg, pulse pressure variation [PPV], stroke volume variation [SVV], systolic blood pressure variation [SPV]) (figure 1 and figure 2) [60]. Normal respiratory variations in these dynamic parameters are <10 percent [62], with greater variations suggesting fluid responsiveness (see "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness') [63]. Unfortunately, all these methods that are based on respiratory-circulatory interactions depend on unchanging patterns of positive pressure mechanical ventilation, which are frequently not maintained during the various phases of cardiac operations (eg, surgical requests to "breath hold" or alter tidal volume).
Further details regarding fluid management during cardiac and other major surgical procedures are available in separate topics:
●(See "Anesthesia for cardiac surgery: General principles", section on 'Prebypass fluid management'.)
●(See "Intraoperative fluid management".)
Hemostasis and blood management — We agree with the 2019 guidelines developed by the Society of Cardiovascular Anesthesiologists (SCA) for management of hemostasis in patients participating in ERACS protocols [8]. These include use of point-of-care (POC) viscoelastic coagulation tests (eg, thromboelastography [TEG] or an adaptation of TEG known as rotational thromboelastometry [ROTEM]) to guide transfusion therapy (table 6).
With TEG or ROTEM tests, a tracing result provides information regarding clot initiation, kinetics of clot formation, clot strength, and fibrinolysis (figure 3 and figure 4 and table 6):
●Primary fibrinolysis (figure 5A-B)
●Secondary hyperfibrinolysis (figure 5A, 5C)
●Thrombocytopenia (figure 5A, 5D)
●Clotting factor consumption (figure 5A, 5E)
●Hypercoagulability (figure 5A, 5F)
Further details regarding use of POC testing and algorithms to manage unacceptable microvascular bleeding during or after cardiac surgery are discussed in separate topics:
●(See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)
●(See "Clinical use of coagulation tests", section on 'Point-of-care testing'.)
Hemodynamic management — Episodes of either low or high blood pressure (BP) during CPB have been associated with increased risk for PND, possibly due to an individual patient's inability to compensate via cerebral autoregulation [43,64-66]. However, a causative relationship has not been established. (See 'Neurocognitive function' above and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Avoid extremes of blood pressure'.)
During CPB, if pump flow is adequate, mean arterial pressure (MAP) is generally maintained at 50 to 80 mmHg, although higher targets may be selected for older patients or those with cerebrovascular disease. However, there is no universally accepted definition for adequate BP values during cardiac surgery, and there is considerable individual variability in the lower limit of MAP for cerebral autoregulation [67]. Thus, estimation of an optimal target range is difficult to predict for a given patient. (See "Management of cardiopulmonary bypass", section on 'Mean arterial pressure' and "Management of cardiopulmonary bypass", section on 'Pump flow and mixed venous oxygen saturation'.)
Temperature management — Continuous assessment of core body temperature is part of any ERACS program [2,3]. Careful perioperative thermoregulation during cardiac surgery may reduce risk for adverse neurologic, transfusion-related and infectious outcomes [68,69].
Although the final target temperature for separation from CPB is 37°C at the nasopharyngeal site, as a practical matter, we also ensure that the core temperature is brought to at least 35.5°C before separation from CPB. However, hyperthermia must be avoided during and after rewarming from CPB. Hyperthermia with brain temperature >37°C increases risk for postoperative cerebral dysfunction, surgical site infection, and acute kidney injury [70-72].
Likewise, hypothermia is also avoided after rewarming during CPB to minimize coagulopathy due to impairment of platelet aggregation and reduced activity of clotting enzymes. Active warming techniques must be employed to achieve normothermia during the rewarming phase of CPB, and then normothermia should be maintained during the postbypass and postoperative periods. (See "Management of cardiopulmonary bypass", section on 'Management during rewarming and weaning' and "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass", section on 'Maintenance of normothermia'.)
Further discussion regarding temperature management during various phases of cardiac surgery is available elsewhere. (See "Management of cardiopulmonary bypass", section on 'Temperature' and "Perioperative temperature management".)
Glucose management — We agree with professional society guidelines for glucose management in patients participating in ERACS protocols, which recommend maintaining blood glucose levels <180 mg/dL (10 mmol/L) during CPB and the postbypass period, as described in detail in separate topics [2,3,73,74]. (See "Management of cardiopulmonary bypass", section on 'Glucose' and "Glycemic control in critically ill adult and pediatric patients".)
Nausea and vomiting prophylaxis — Prevention of postoperative nausea and vomiting (PONV) is emphasized in many ERACS protocols [3,7]. We administer IV dexamethasone 4 mg at the beginning of the case and IV ondansetron 4 mg shortly before transporting the patient to the ICU as part of our ERACS protocol [75]. In addition, we maintain normothermia, euvolemia, and employ a multimodal pain management approach that minimizes opioid dosing, as described in the sections above, as these efforts are associated with decreased risk for PONV. (See "Postoperative nausea and vomiting".)
POSTOPERATIVE MANAGEMENT — Postoperative management of patients participating in an enhanced recovery program after cardiac surgery (ERACS) program is similar to routine postoperative care, as described in a separate topic. (See "Postoperative care after cardiac surgery".)
OUTCOMES — Compared with conventional care, limited data regarding outcomes suggest that implementation of an ERACS program is associated with reductions in time to postoperative extubation, less postoperative opioid administration, and reduced length of stay in the intensive care unit and hospital [7,25,33,76,77]. Some studies have also noted lower incidences of surgical and medical complications, improved analgesia, and decreased overall costs [7,77].
The likelihood of achieving the goals of an ERACS program is associated with the degree of compliance with program elements [25]. A challenge in determining efficacy of such programs is the fact that ERACS goals and measured outcomes are typically institution-specific, which limits generalizability of published study results.
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
●Goals for enhanced recovery – Protocols for enhanced recovery after cardiac surgery (ERACS) include standardized multidisciplinary perioperative approaches for elective cardiac procedures with the goals of minimizing stress responses, using multimodal analgesic strategies, achieving early extubation, decreasing hospital length of stay, expediting recovery, and reducing postoperative complications. (See 'Goals of enhanced recovery after cardiac surgery' above.)
●Preoperative strategies – Prehabilitation to achieve optimal preoperative condition may include assessment of frailty, nutritional status, and whether referral for smoking cessation is necessary. Other aspects of a standard preanesthetic consultation include education of the patient and family regarding planned use of multimodal analgesic techniques, management of perioperative medications, and expectations for early extubation and postoperative recovery in an ERACS program. (See 'Preoperative period' above.)
●Day of surgery strategies
•Planned multimodal pain management – Pain management strategies during the preoperative, intraoperative, and postoperative periods includes limited use of short-acting opioids, as well as nonopioid analgesic agents and techniques (see 'Multimodal pain management' above):
•Minimize benzodiazepine premedication. (See 'Minimize use of benzodiazepine premedication' above.)
•Minimize fasting – Guidelines established by international anesthesia societies are followed (table 2), and some centers encourage consumption of clear liquids until two to four hours before anesthesia. (See "Preoperative fasting in adults" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative considerations'.)
●Selection of neuromuscular blocking agents – If neuromuscular blockade is desired throughout the surgical procedure, neuromuscular function should be assessed with a peripheral nerve stimulator (PNS) to maintain an appropriate degree of neuromuscular blockade. We also perform quantitative assessment with a PNS at the end of the procedure, and we fully reverse the neuromuscular blocking agent (NMBA) before the patient leaves the operating room. (See 'Selection and dosing of neuromuscular blocking agents' above.)
●Fluid management – We employ a zero-balance fluid management strategy during the prebypass and postbypass periods, with the aim of maintaining central euvolemia while minimizing excess salt and water. When hypovolemia is suspected as a result of dehydration or blood loss, we administer an IV fluid challenge (typically a bolus of 250 mL) to assess intravascular fluid responsiveness (figure 1 and figure 2). Guidelines developed for goal-directed fluid therapy are used by some centers. (See 'Fluid management' above.)
●Blood and hemostasis management – We agree with the 2019 guidelines developed by the Society of Cardiovascular Anesthesiologists (SCA) for management of hemostasis in patients participating in ERACS protocols. These include use of point-of-care (POC) viscoelastic coagulation tests (eg, thromboelastography [TEG] or an adaptation of TEG known as rotational thromboelastometry [ROTEM]) to guide transfusion therapy (table 6 and figure 3 and figure 4). (See 'Hemostasis and blood management' above.)
●Hemodynamic management – Intraoperative management of hemodynamics, temperature, and glucose, while fastidious, are similar to management for all patients undergoing a cardiac surgical procedure. (See 'Hemodynamic management' above and 'Temperature management' above and 'Glucose management' above.)
●Nausea and vomiting prophylaxis – We administer IV dexamethasone 4 mg at the beginning of the case and IV ondansetron 4 mg shortly before transporting the patient to the intensive care unit (ICU) to prevent postoperative nausea and vomiting (PONV). (See 'Nausea and vomiting prophylaxis' above.)
●Outcomes – Compared with conventional care, limited data regarding outcomes suggest that implementation of an ERACS program is associated with reductions in time to postoperative extubation, less postoperative opioid administration, and reduced length of stay in the intensive care unit and hospital. The likelihood of achieving these goals is associated with the degree of compliance with program elements. (See 'Outcomes' above.)
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