Recommendations for fast-track extubation in adult cardiac surgery patients: a consensus statement

Introduction: Enhanced recovery after cardiac surgery in selected low-risk patients, has the potential to improve outcomes and reduce the burden of healthcare costs. Anesthesia-related challenges play a major role in the successful implementation of Enhanced Recovery After Surgery (ERAS) protocols, with particular emphasis placed on fast-track extubation. Acknowledging the importance of this practice, the Italian Association of Cardiac Anesthesiologists and Intensive Care (ITACTAIC) has advocated for an initiative to establish a consensus offering practical recommendations for fast-track extubation after adult cardiac surgery. Evidence acquisition: After conducting a systematic review, all randomised control trials (RCTs) published between 2013 and 2023 were meticulously selected and analysed during a consensus meeting that involved statement voting. Evidence synthesis: Out of the 2268 publications identified using the search string, 60 RCTs were selected and classified into six groups, each evaluating specific interventions associated with extubation within 6 hours post-surgery. The authors examined 20 RCTs pertaining to loco-regional anesthesia, 19 analysing elements of general anesthesia, 12 focused on surgery-related aspects and techniques, three examining ventilation, two exploring anesthesia depth monitoring, and four addressing miscellaneous aspects. The expert panel approved 16 statements with 15 achieving high agreement and one obtaining moderate agreement. Finally a total of eight interventions were considered associated with fast-track extubation: parasternal block, erector spinae plane block, alpha agonist in the operating room (OR), opioids in the OR, dexmedetomidine in the intensive care unit (ICU), minimal invasive surgical access, anesthesia depth monitoring, adaptative support ventilation. Conclusions: In the first consensus document ever published by a scientific society addressing practical recommendations for fast-track extubation post-cardiac surgery, the authors identified sixteen interventions commonly associated with fast-track extubation in selected adult cardiac surgery patients.