These resources summarize ERAS® Cardiac recommendations by phase of care: before, during, and after surgery. Each topic links to a PDF with supporting evidence and practical considerations. Recommendations are intended to support quality improvement and shared decision-making within local protocols.
Jump to section
Summary
2024 ERAS Expert Recommendations for Cardiac Surgery
Includes Level of Evidence (LOE)
2019 ERAS Expert Recommendations for Cardiac Surgery
Includes Class of Recommendation (COR) and Level of Evidence (LOE)
General
Patient engagement through shared decision-making
Patient engagement is improved through the incorporation of shared decision-making principles.
Establishment of a Multidisciplinary Team
Program implementation and sustainment is facilitated through the establishment of a multidisciplinary team, including a dedicated coordinator, as an extension of the Heart Team.
Compliance and Outcomes Auditing
Routine auditing and evaluation of perioperative process measure adherence and clinical outcomes is a necessary component of high-quality perioperative care.
Before Surgery
Alcohol & Smoking Cessation
Smoking and hazardous alcohol consumption should be stopped 4 weeks before elective surgery.
A1C and Correction of Nutritional Deficiency
Preoperative measurement of hemoglobin A1c is recommended to assist with risk stratification.
Avoidance of Prolonged Fasting
Clear liquids may be continued up until 2-4 hours before general anesthesia.
Limiting Nil Per Os Status
Limiting nil per oz status for clear liquids (>2 hours before surgery) is reasonable after assessment of potential risk factors for aspiration.
Multicomponent Prehabilitation
Multicomponent prehabilitation may be considered to optimize patients prior to non-urgent cardiac surgery.
Patient Engagement Technology
Patient engagement tools, including online/application-based systems to promote education, compliance, and patient-reported outcomes are recommended.
Prehabilitation
Prehabilitation is recommended for patients undergoing elective surgery with multiple comorbidities or significant deconditioning.
Preoperative Screening and Risk Assessment
Multifaceted patient screening and risk assessment improves the informed consent process and allows for advanced perioperative planning.
During Surgery
Antifibrinolytics
Tranexamic acid or epsilon aminocaproic acid is recommended during on-pump cardiac surgical procedures.
Avoidance of Hyperthermia
Hyperthermia (>37.9 C) while rewarming on cardiopulmonary bypass is potentially harmful and should be avoided.
Central Nervous System Monitoring
Central nervous system monitoring may provide an early indication of neurologic risk, but additional study is necessary to identify strategies to prevent and mitigate injury.
Goal-Directed Perfusion
Goal-directed perfusion may play a role in preventing organ injury associated with cardiopulmonary bypass.
Infection Reduction Bundle
A care bundle of evidenced based best practices is recommended to reduce surgical site infections.
Optimization of Sternal Closure
Rigid sternal fixation can be useful to improve/accelerate sternal healing and reduce mediastinal wound complications.
Postoperative Nausea and Vomiting Prevention
Standardized risk factor assessment and prophylaxis has been shown to prevent postoperative nausea and vomiting.
Protective Lung Ventilation
Mechanical ventilation with lung-protective strategies is associated with improved mechanics and fewer pulmonary complications.
Transesophageal Echocardiography
Transesophageal echocardiography is encouraged in patients with moderate or high risk of perioperative morbidity or mortality.
Use of Pulmonary Artery Catheters
Pulmonary artery catheters use in low-risk patients or procedures incurs greater health care resource utilization without improving morbidity or mortality.
Ventilation On Cardiopulmonary Bypass
The role of mechanical ventilation during cardiopulmonary bypass is uncertain.
After Surgery
AKI Prevention and Management
Routine screening for and, where appropriate, the use of a comprehensive treatment care bundle can reduce the incidence and severity of postoperative acute kidney injury.
Avoidance of Hypothermia
Persistent hypothermia after CPB should be avoided in the early postoperative period.
Biomarkers for Acute Kidney Injury
Early detection of kidney stress and interventions to avoid acute kidney injury are recommended following surgery.
Chest Drain Management
Stripping or breaking the sterile field of chest tubes to remove clot is not recommended. Maintenance of chest tube patency is recommended to prevent retained blood.
Delirium Screening
Postoperative systematic delirium screening is recommended at least once per nursing shift.
Early Extubation
Structured strategies to facilitate extubation within 6 hours of surgery have been shown to be safe and potentially hasten recovery after elective procedures.
Glycemic Control
Perioperative glycemic control is recommended. An insulin infusion is recommended to treat hyperglycemia in all patients postoperatively.
Goal-Directed Therapy
Goal directed fluid therapy is recommended to reduce postoperative complications.
Intraoperative Extubation
Highly selective intraoperative or immediate postoperative extubation may be appropriate for patients undergoing low-risk cardiac surgery.
Multimodal Analgesia
A multimodal, opioid-sparing, pain management plan is recommended postoperatively.
Postoperative Activity and Sternal Precautions
Early postoperative ambulation and upper extremity exercise is well tolerated and associated with hastened recovery.
Thromboprophylaxis
Chemical thromboprophylaxis is recommended following surgery.
Multiphase
Goal-Directed Therapy
Goal-directed fluid and hemodynamic therapy can guide perioperative resuscitation and prevent postoperative organ injury.
Opioid-Sparing Pain Management
A multimodal approach reduces reliance on opioid-based analgesia and optimizes perioperative pain management.
Patient Blood Management Program
Blood product utilization and associated outcomes are optimized through the implementation of a comprehensive patient blood management program.
Postoperative Atrial Fibrillation Prevention
Postoperative atrial fibrillation is optimally addressed through the use of a multifaceted prevention strategy.
Regional Analgesia
Chest wall regional analgesia can be an effective component of a multimodal approach to perioperative pain management.
Surgical Site Infection Prevention Bundle
The bundled application of evidence-based best practices has been shown to prevent surgical site infection.
Systematic Delirium Screening and Prevention
Routine use of a systematic delirium screening tool and nonpharmacologic strategies aid the identification and prevention of postoperative delirium.