Clinical and Inflammatory Outcomes Following Multimodal Anesthesia and On-Table Extubation in Elderly Patients Undergoing Elective Cardiac Surgery with (Partial) Sternotomy: A Secondary Analysis of RERACS Study

Background: Enhanced Recovery After Cardiac Surgery (ERACS) is a multimodal approach aiming for optimized postoperative outcomes. Regarding demographic change and the epidemiology of heart diseases, ERACS concepts with on-table extubation (OTE) might be a resource-aware solution needed to ensure adequate perioperative surgical care to an aging society. We investigated clinical outcomes and inflammatory effects of ERACS with multimodal anesthesia and OTE in patients >65 years undergoing elective cardiac surgery. Methods: This study is a secondary analysis of the RERACS study (Regensburg Enhanced Recovery After Cardiac Surgery). Sixty-four elderly RERACS patients were compared with a retrospective control group (age >65 years, n = 67) undergoing elective cardiac surgery via (partial) sternotomy. The RERACS concept consisted of shortened fasting periods, breathing training, opioid-sparing multimodal analgesia, OTE, patient-reported outcome measures and additional exploratory evaluation of Interleukin-6 (IL-6) and TNF-alpha in this secondary analysis. The control group received standard care with extubation in the intensive care unit (ICU). Results: Unadjusted baseline analysis showed no significant differences between the two groups. Length of stay in ICU (ICU-LOS) and postoperative catecholamine weaning were significantly shorter in the RERACS group. RERACS patients showed significantly lower C-reactive-protein levels 24 h after surgery than control patients. In the RERACS group, postoperative low interleukin-6 levels were associated with postoperative complications like delirium or infection, but not with atrial fibrillation. Patient-reported outcome measures in the RERACS group showed high patient satisfaction, good pain compensation and low levels of postoperative nausea and vomiting but remarkable levels of sore throat/hoarseness, despite shorter ventilation time. Conclusions: Data support that ERACS with OTE is feasible in selected elderly patients undergoing elective cardiac surgery via (partial) sternotomy. No apparent increase in required postoperative respiratory support occurred compared to patients with conservative, prolonged mechanical ventilation. The RERACS program with multimodal anesthesia and OTE was associated with shorter ICU-LOS, earlier weaning from vasoactive support, and high patient satisfaction. Further studies are needed to evaluate immunomodulatory effects of ERACS measures and investigate the role of IL-6 levels as a marker for immunoparalysis in elderly cardiosurgical patients.