الفهرس 
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Abstract
Enhanced Recovery after Surgery (ERAS) is a multimodal, trans-disciplinary care initiative to promote swift recovery of surgical patients. Such program aims to reduce complications, shorten the period of hospital stay, reducing costs and eventually speed up the patient return to his preoperative daily routine. Multiple challenges encounter the cardiac surgery patients postoperatively, unrelated to their cardiac performance with respiratory complications and pain being the most encountered.
Conventional oxygenation methods used to correct hypoxemia are limited by patient intolerance to the application system and by the flow being delivered under non-optimal temperature and humidity conditions. In addition, having a maximum flow of 15 l/min may fail to cover the minute ventilation of patients in respiratory failure ending by inhaled flow being mixed with air from the atmosphere and dropping the fraction of inspired oxygen. High flow nasal oxygen therapy carries the benefit of reducing the dilution of the administered oxygen, dead space washout, the generation of continuous positive airway pressure (CPAP) and improving mucociliary transport due to the active humidification and heating of the administered gas.
Utilization of regional blocks in cardiac surgery have been shown to provide improved post-operative pain control and decreased opiate requirements with less possible complications.
The aim of the present study was to compare two protocols of postoperative care in cardiac surgery patients; an enhanced recovery protocol versus conventional postoperative care.
Fifty-three adult patients above the age of 18 undergoing elective cardiac surgery that required the utilization of cardiopulmonary bypass and median sternotomy approach were enrolled in the study, three of which were soon excluded due to follow up failure and the remaining 50 were randomly allocated into two groups using closed envelope method.
In the ERAS Care group, Patients received ultrasound guided pectointercostal fascial plane block. Patients were extubated onto HFNO. In CONV care group, patients received 1 µg/kg of IV fentanyl bolus dose, followed by fentanyl IV infusion. patients were extubated onto a simple facemask. The need to escalate the respiratory support was defined as respiratory rate above 30 breaths per minute, severe dyspnea or oxygen saturation below 92% on simple faceamsk. Patients in both groups received 5 mg IV Nalbuphine as a rescue analgesia every 3hours if their numeric pain rating scale score was more than 5 or in case of break through pain.
Both groups were statistically comparable regarding sex, age, BMI, smoking status, incidence of pre-existing respiratory disease, type of surgery performed and the amount of packed red blood cells transfused either intraoperatively and 48 hours post-operatively.
The ERAS based protocol led to an earlier extubation when compared to the conventional care protocol. ICU stay was significantly shorter among the ERAS group participants in comparison with that of the CONV care group. However, the duration of hospital stay was comparable in both groups. Time to first unsupported mobilization was comparable in both groups.
The numeric pain rating scale scores are dramatically significantly lower in the ERAS group with less participants needed rescue doses of nalbuphine in this group versus the CONV care group participants. However, in the present study once rescue nalbuphine was needed, the doses required were not statistically different among participants in both groups.
Oxygenation (hypoxic index) was found to be significantly better in the ERAS group participants in all readings except for that calculated 12 hours post-extubation. The respiratory rate was comparable in both groups in the first 24hours and significantly lower among the ERAS group participants over the following 24 hours. Participants showed better satisfaction and comfort as measured by the modified Borg score in the ERAS group. In the present study, roughly 3 times the number of participants in the CONV care group required escalation of the respiratory support compared to the ERAS care ones. Participants in the ERAS care group showed better lung aeration proved by lower scores in modified radiological atelectasis score and modified lung ultrasound score.
Gastrointestinal complications were comparable in both groups. Participants in the CONV care group showed more findings in the predischarge radiological screening. Atelectasis was by far the most common finding.