Enhanced recovery and fast track recovery programmes, also known as Enhanced Recovery after Surgery (ERAS), are defined as multimodal evidence-based and procedure specific pathways to optimize the perioperative care, recovery and discharge of surgical patients [1].

      Over the past two decades enhanced recovery principles have been implemented across various surgical specialties and there is compelling evidence from the meta analyses of multiple randomized controlled trials that there is a benefit of fast track recovery post major general abdominal and urological surgery [2-5]. However, it is unclear how these relate to the post cardiac surgery population [6].

      The factors driving this change are pressures on surgeons to decrease resource consumption while increasing operation numbers on an increasingly co-morbid aging population, without compromising safety and quality of care. There are additional financial pressures on all health care systems to deliver optimal high-quality care with increasing efficiency savings.

      The principles of fast track recovery programmes focus on pre-, intra- and postoperative components and rely on interdisciplinary communication and support (Figure 1). The implementation of these programmes is protocol based. Fast track recovery protocols include numerous components [7].

Figure 1: Principles of fast track recovery programmes.

      These include pre-operative optimisation of patient’s haematinics, lung function, exercise capacity, smoking cessation, weight loss where possible and low-risk patient selection.

      Patients undergo intense counselling on the postoperative rehabilitation processes and discharge plans. Patients receive preoperative carbohydrate loading whilst prolonged preoperative fasting and pre-medications are avoided.

      The core intraoperative components include minimally invasive surgery and minimally invasive surgery using mini-cardiopulmonary bypass circuits, a goal-directed fluid and normothermic management and short-acting anaesthetics.

      The post-operative care aims to deliver protocoled early extubating, judicious fluid management, multimodal pain management, prophylaxis for nausea and vomiting, early removal of lines, drains and catheters; early mobilisation and feeding and dietary supplementation with high protein drinks.

      The outcome measures that are analysed are length of intubation, duration of ITU and hospital stay, any complications and mortality.

      The necessity of the implementation of fast track recovery programmes in adult cardiac surgery have widely been discussed. However, these strategies are not adopted in many cardiac surgery programmes and there remain numerous individual and institutional barriers to their uptake. We aimed to analyse the outcomes for adult cardiac surgical programmes to assess how they impact on patient care.

Search strategy and outcomes

      OVID MEDLINE® and Pubmed Index from 1999 to May 2018 were searched using the following terms: [fast-track recovery programme] OR [fast-track recovery programme] OR [fast-track surgery] AND [cardiac surgery] OR [cardiac procedures] AND [outcome] OR [stay].

      164 papers were found using the reported search. From these seven papers were identified that provided the best evidence to answer the question. Four compared fast-track recovery with conventional recovery (Table 1), three looked at complications and reasons for failure in fast-track recovery groups (Table 2).

Table 1

Table 1: Fast track recovery in adult cardiac surgery

Table 2

Table 2: Outcomes after fast track recovery programme failure

      The terms enhanced recovery, fast track recovery programmes and Early Recovery after Surgery (ERAS) have been used interchangeably for similar programmes in the literature. In this paper we will refer to all these terms as fast track recovery programmes.

      The feasibility of fast-track recovery after cardiac surgery was studied in prospective [8,9] and retrospective studies [10]. These report that the total number of patients with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, cardiac tamponade and myocardial infarction) were significantly reduced in the fast-track recovery group (50,3% vs. 19.2%, p<0.01).8 The fast-track recovery pathway led to a reduced length of stay in an intensive care facility (p<0.001) [9,10]. However, the median total hospital Length Of Stay (LOS), incidence of complications, re-intubation and readmission were similar [8,9]. A retrospective study showed a significantly shorter intermediate care unit (21 hours (17–39) vs. 26 hours (19- 49), p<0.01) and hospital stay (10 days (8-12) vs. 11 days (9-14), p<0.01) [10].

      Postoperative pain scores on the first three postoperative days were significantly lower in the fast-track recovery group (p < 0.01, p < 0.05, p < 0.01) whilst morphine was given for a significantly shorter period postoperatively (3 days (2-3) vs. 0 days (0-0), p < 0.01) [8]. The duration of intubation was reduced from 1 to 14 hours (p <0.001) [8,10].

      The mean cost of the perioperative care for fast-track recovery was £4182±2284 compared to £4553±1355 for the conventional group with a mean difference of £371 per patient (£166- £1324, p<0.001) [9].

      One prospective randomised trial evaluated Minimal Extracorporeal Circulation Circuits (MECC) compared with conventional CPB in facilitating fast-track recovery after elective coronary bypass grafting [11]. Fast-track recovery was significantly higher in patients undergoing MECC (25% vs. 6,7%, p=0.006). MECC was identified as an independent predicting factor for fast-track recovery (OR 3.8, p=0.011). The duration of ventilation (p<0.001), hospital stay (p=0.02), intraoperative (p<0.001) and postoperative (p=0.009) blood transfusions, inotropic support (p<0.001), intra-aortic balloon pump (p=0.03), postoperative atrial fibrillation (p=0.03) and renal failure (p=0.02) was significantly lower in the MECC group.

      Readmission rates of 3.29% were described in a fast-track recovery group in a prospective observational study [12]. Patients who required readmission had a significantly prolonged ICU stay compared with the initial ICU stay (105.6+/-180.0 versus 19.2+/-2.4 hours, p<0.001) [12].

      Two retrospective cohort studies analysed the reasons for fast-track recovery failure [13,14]. Failure was defined as any transfer of the patient back to the ICU (primary 11.6%, secondary 5.6%). Risk factors were assessed in a multivariate regression analysis. Age over 70 years (p<0.01, OR 2.2), [13,14] female gender (p<0.01, OR 1.5), [13] prolonged operation times (p<0.01), [13] prolonged cross-clamp times (p<0.01) [13] and left ventricular dysfunction could be defined as independent risk factors for fast-track recovery failure [14].

      Over the past two decades minimally invasive surgical techniques and enhanced recovery programmes have become the primary methods of improving recovery after surgery, thus providing better short-term outcomes. They focus on pre-, intraand postoperative components, seeking to provide a holistic approach of interdisciplinary care and are optimizing the use of resources for perioperative care.

      Small retrospective and prospective studies demonstrate fast track recovery after cardiac surgery as an important management strategy in carefully pre-selected patient groups with beneficial effects with respect to potentially decreased duration of intubation, total length of ITU/hospital stay, less postoperative complications und cost effectiveness compared to conventional recovery.

      Different independent risk factors have been shown to predict failure in a fast track process post-surgery. Among all the pre-operative variables, emergency operation, increasingly complex operations, age, renal function, pre-procedure stroke, redo surgery, impaired left ventricular function and female gender were identified as the most important variables to prolonged ITU stay and complications. In a systematic review 20 models for risk prediction of ITU stay post adult cardiac surgery were assessed. The Parsonnet and Euro SCORE were identified as superior models to allow prognostication [15]. It is imperative that they form the basis of patient selection for the success of the fast track recovery programmes.

      Limitations of this review should be considered as most studies focused on different elements of fast track recovery and included different patient groups. There is a lack of randomised trial and prospective data assessing which components of the fast-tracking system contribute most to the outcomes. Further large-scale pooled studies would be useful to assess how these results can be applied to those patients in the intermediate and high-risk groups as they would benefit the most from the adoption of these strategies.

      We conclude that fast track recovery programmes after cardiac surgery are safe, and feasible to conduct. An interdisciplinary agreement on the management of patients and the most important fast-track elements and rigid and strict discharge criteria are important factors that contribute to the success of these programmes.

      The support and awareness of operative care practitioners, nursing staff, physiotherapist, pharmacists, nutritionists and social workers are of up most importance for the implementation of fast track recovery programmes.