Spadaccio Cristiano, Salsano Antonio, Pisani Angelo, Nenna Antonio, Nappi Francesco, Osho Asishana, D'Alessandro David, Sundt Thoralf M, Crestanello Juan, Engelman Daniel, Rose David
Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Cardiac Surgery, Massachusetts General Hospital (MGH) - Harvard Medical School, Boston, Massachusetts, USA.
World J Surg. 2024 Apr;48(4):779-790. doi: 10.1002/wjs.12122. Epub 2024 Feb 29.
Previous meta-analyses combining randomized and observational evidence in cardiac surgery have shown positive impact of enhanced recovery protocols after surgery (ERAS) on postoperative outcomes. However, definitive data based on randomized studies are missing, and the entirety of the ERAS measures and pathway, as recently systematized in guidelines and consensus statements, have not been captured in the published studies. The available literature actually focuses on "ERAS-like" protocols or only limited number of ERAS measures. This study aims at analyzing all randomized studies applying ERAS-like protocols in cardiac surgery for perioperative outcomes.
A meta-analysis of randomized controlled trials (RCTs) comparing ERAS-like with standard protocols of perioperative care was performed (PROSPERO registration CRD42021283765). PRISMA guidelines were used for abstracting and assessing data.
Thirteen single center RCTs (N = 1704, 850 in ERAS-like protocol and 854 in the standard care group) were selected. The most common procedures were surgical revascularization (66.3%) and valvular surgery (24.9%). No difference was found in the incidence of inhospital mortality between the ERAS and standard treatment group (risk ratio [RR] 0.61 [0.31; 1.20], p = 0.15). ERAS was associated with reduced intensive care unit (standardized mean difference [SMD] -0.57, p < 0.01) and hospital stay (SMD -0.23, p < 0.01) and reduced rates of overall complications when compared to the standard protocol (RR 0.60, p < 0.01) driven by the reduction in stroke (RR 0.29 [0.13; 0.62], p < 0.01). A significant heterogeneity in terms of the elements of the ERAS protocol included in the studies was observed.
ERAS-like protocols have no impact on short-term survival after cardiac surgery but allows for a faster hospital discharge while potentially reducing surgical complications. However, this study highlights a significant nonadherence and heterogeneity to the entirety of ERAS protocols warranting further RCTs in this field including a greater number of elements of the framework.
以往结合心脏手术随机和观察性证据的荟萃分析表明，术后加速康复方案（ERAS）对术后结局有积极影响。然而，缺乏基于随机研究的确切数据，并且已发表的研究未涵盖最近在指南和共识声明中系统化的全部ERAS措施和路径。现有文献实际上侧重于“类ERAS”方案或仅少数ERAS措施。本研究旨在分析所有在心脏手术中应用类ERAS方案的随机研究的围手术期结局。
对比较类ERAS与围手术期标准护理方案的随机对照试验（RCT）进行荟萃分析（PROSPERO注册号CRD42021283765）。采用PRISMA指南提取和评估数据。
选择了13项单中心RCT（N = 1704，类ERAS方案组850例，标准护理组854例）。最常见的手术是外科血管重建术（66.3%）和瓣膜手术（24.9%）。ERAS组和标准治疗组的住院死亡率无差异（风险比[RR] 0.61 [0.31; 1.20]，p = 0.15）。与标准方案相比，ERAS与重症监护病房住院时间缩短（标准化均数差[SMD] -0.57，p < 0.01）、住院时间缩短（SMD -0.23，p < 0.01）以及总体并发症发生率降低相关（RR 0.60，p < 0.01），这是由卒中发生率降低（RR 0.29 [0.13; 0.62]，p < 0.01）驱动的。观察到研究中纳入的ERAS方案要素存在显著异质性。
类ERAS方案对心脏手术后的短期生存无影响，但可使患者更快出院，同时可能减少手术并发症。然而，本研究强调了对整个ERAS方案存在显著的不依从性和异质性，这需要在该领域进行更多的RCT，包括纳入框架中的更多要素。
