ERAS in High-risk Patients: Improvement of Clinical Outcomes

Background: Enhanced Recovery After Surgery (ERAS) uses a multidisciplinary, evidence-based approach to improve overall outcomes and length of stay for patients undergoing surgery. Multimorbid patients in particular could benefit from the ERAS protocol. This study aims to show the effects of an ERAS routine in patients undergoing high-risk surgery according to the ERAS guidelines.

Methods: The ERAS protocol with preoperative appointments and dedicated prehabilitation was applied to a total of 93 patients from June 2023 to July 2024. According to the ERAS guidelines, procedures such as root repair/replacement, ascending aortic replacement, Ross procedure, redo procedures, and combined valve procedures are defined as high-risk procedures. Of the 93 ERAS patients, 31 patients were considered high risk for ERAS (high risk group) compared with 62 low-risk patients (low-risk group).

Results: The high-risk group was significantly younger (high-risk: 57.5 ± 7.8 versus low-risk: 60.9 ± 6.2; p = 0.024) and had a higher EURO-Score II (high-risk: 1.5 ± 0.89 versus low-risk: 0.87 ± 45; p = 0.001). Other baseline characteristics were similar in both groups. Cardiopulmonary bypass time (p = 0.205) and aortic cross-clamp time (high-risk: 101.9 ± 46.2 versus low-risk: 84.3 ± 23.9; p = 0.088) were similar in both groups. Extubation in the OR was possible in 35.4% of the high-risk group and 34% of the low-risk group (p = 0.932). Reintubation was required for postoperative bleeding in 2/31 patients (high-risk) and 2/62 (low-risk) patients. Admission to PACU-24 instead of ICU was possible in 32% of high-risk and 53% of low-risk patients (p = 0.056). One low-risk patient had postoperative delirium. ICU readmission was required in 2/31 (high-risk) and 2/62 (low-risk) patients (p = 0.470). ICU stay (high-risk: 28.5 ± 23.4 versus low-risk: 32.9 ± 30.7; p = 0.481) and postoperative hospital stay (high-risk: 8.6 ± 3.8 versus low-risk: 7.2 ± 2.9; p = 0.084) were similar in both groups.

Conclusion: ERAS protocols can also be safely implanted in more complex patients such as combined valve procedures, Ross procedures, and/or redo procedures. However, a dedicated multi-professional team with a dedicated ERAS nurse is required to manage these multimorbid patients within the ERAS protocol.

Publication History

Article published online:
11 February 2025