An Integrated ERAS–PBM Pathway for Cardiac Surgery: Insights and Outcomes

Background/Objectives: Anemia is a common condition in cardiac surgery and is strongly associated with adverse outcomes, including higher transfusion requirements, increased morbidity, and prolonged hospital stay. Enhanced Recovery After Surgery (ERAS) and Patient Blood Management (PBM) are both multimodal strategies designed to improve perioperative care. This study evaluates the impact of integrating ERAS and PBM with preoperative anemia management into a single standardized pathway in elective cardiac surgery. Methods: We conducted a retrospective, single-center before–after study at Lausanne University Hospital, comparing a pre-ERAS cohort (2019) with a prospective cohort managed under the ERAS–PBM pathway (May 2023–November 2024). The ERAS–PBM pathway included systematic preoperative anemia screening and treatment, reinforcement of adherence to existing restrictive transfusion thresholds, optimized blood conservation techniques, and standardized perioperative care bundles coordinated by a dedicated ERAS nurse. The primary outcome was the rate of red blood cell (RBC) transfusions during hospitalization. Secondary outcomes included overall transfusion rates, hemoglobin levels, complications, and length of stay. Results: A total of 391 patients were included (ERAS, n = 229; pre-ERAS, n = 162). RBC transfusion rates were significantly lower in the ERAS group (23.6% vs. 38.9%, p = 0.0012), with a reduction in the number of units per patient (p = 0.0005). Hemoglobin at admission was higher in the ERAS cohort (139.5 vs. 134 g/L, p = 0.0009). Overall complication rates decreased (46.3% vs. 66.7%, p < 0.0001), including major adverse cardiovascular events and pulmonary complications. Hospital stay was shorter (9 vs. 12 days, p < 0.0001), as was mechanical ventilation time (0 vs. 2.1 h, p < 0.0001). Anemic patients at admission were more transfused (39.3% vs. 18.6%, p = 0.002). Within the ERAS group, RBC transfusion was associated with higher rates of selected postoperative complications and longer ICU and hospital stays. In an exploratory multivariable logistic regression analysis, ERAS–PBM implementation was associated with lower odds of RBC transfusion during hospitalization (adjusted OR 0.59, 95% CI 0.36–0.98; p = 0.041). Conclusions: The integration of ERAS and PBM into a single multimodal pathway was associated with significant reductions in transfusion rates, complications, and length of stay in elective cardiac surgery. Anemia at admission and perioperative transfusion were associated with worse outcomes, emphasizing the importance of anemia management. Larger, multicenter prospective studies are warranted to confirm these results and to optimize anemia correction strategies, including earlier treatment of iron deficiency and outpatient erythropoietin use.