Improved Recovery Protocols in Cardiac Surgery: A Systematic Review and Meta-Analysis of Observational and Quasi-Experimental Studies.

Introduction: Improved recovery protocols were implemented in surgical specialties over the last decade, which decreased anesthetic and surgical stress and the incidence of perioperative complications. However, these recovery protocols were introduced more slowly for cardiac surgeries. The most frequent complications in cardiac surgery are related to patient clinical status and the characteristics of the surgical procedures involved, which are becoming more varied and complex every day. The first version of the enhanced recovery program for cardiac surgery was published in 2019, but its recommendations were based on only a few studies, and scant research has evaluated its implementation. Randomized and controlled clinical trials for these protocols are scarce, so research that summarizes the results of studies with other methodological designs are useful in demonstrating their benefits in cardiovascular surgery services in Cuba and in other limited-resource settings.

Objective: Estimate the effectiveness of improved recovery protocols in the perioperative evolution of patients undergoing cardiac surgery.

Methods: We performed a systematic review and meta-analysis according to the guidelines of manual 5.1.0 for reviews of the Cochrane library. We included observational and quasi-experimental studies published from January 2015 through May 2020 that compared enhanced recovery protocols with conventional treatments in patients older than 18 years, and used a quality score to evaluate them. We used the following sources: the Cochrane Library, PubMed, LILACS, SciELO, EBSCO, Google Scholar, Web of Science, Clinical Key, ResearchGate and HINARI. The following keywords were used for the database searches in English: ERAS, protocols and cardiac surgery, enhanced recovery after cardiac surgery, ERACS, clinical pathway recovery and cardiac surgery, perioperative care and cardiac surgery. We used the following search terms for databases in Spanish: protocolos de recuperación precoz and cirugía cardiaca, protocolos de recuperación mejorada and cirugía cardiaca, cuidados perioperatorios and cirugía cardiaca, programas de recuperación precoz and cirugía cardiovascular. Methodological quality of included investigations was evaluated using the surgical research methodology scale. Meta-analyses were performed for perioperative complications, intensive care unit and hospital stays, and hospital readmission within 30 days of surgery. We calculated effect sizes of the interventions and the corresponding 95% confidence intervals. We used mean differences and confidence intervals for continuous variables, and for qualitative variables we calculated relative risk (RR). Random effects analysis was used. Heterogeneity of the studies was assessed using the Q statistic and the I2 statistic.

Results: We selected 15 studies (a total of 5059 patients: study group, n = 1706; control group, n = 3353). The average quality score for the 15 articles included was 18.9 (out of a maximum of 36 according to the scale) and 66.6% had a score =18. With improved recovery protocols in cardiac surgery, the incidence of perioperative complications decreased (RR = 0.73; 95% CI 0.52-0.98) as did hospital readmission within 30 days after surgery (RR = 0.51; 95% CI 95% CI: 0.31-0.86). Differences in extubation time, hospital stay and length of stay in intensive care units were less marked, but always favored the group in which the enhanced protocols were implemented.

Conclusions: Improved recovery protocols in cardiac surgery increase quality of care evidenced by reductions in perioperative complications and decreased incidence of hospital readmission in the month following surgery.