The effect of preoperative carbohydrate loading and perioperative opioid sparing multimodal analgesia on patient outcomes in Enhanced Recovery After Cardiac Surgery (ERACS) - A randomized controlled trial

ERAS (Enhanced Recovery After Surgery) is a multidisciplinary initiative to improve perioperative care, early discharge and reduce the cost of patients.1 ERAS protocol has already been well established in other surgeries like colorectal, gynecological surgeries and has been widely followed worldwide. There are several important components of ERAS include preop patient education, clear carbohydrate fluid intake in the morning and reduce fasting time, opioid sparing multimodal analgesia, post operative nausea prevention, early extubation and early mobilization. Among these components we have taken two most important components like clear carbohydrate fluid intake in the morning and reduce fasting time and opioid sparing multimodal analgesia, and planning to assess its effect on overall patient postoperative outcome. The studies have shown that preoperative oral carbohydrate intake reduces postoperative insulin resistance and improves glucose metabolism.2 It also helps in early return of gut function3, modifies hormonal and metabolic response, reduces surgical site infections and length of hospital stay. Preoperative oral carbohydrate intake 2 hours before general anesthesia is recommended as a part of Enhanced Recovery After Surgery (ERAS) pathway. But however it is not completely implemented in cardiac surgery due to varying level of evidences.4  ERAS protocol recommends to reduce the opioid usage and follow multimodal analgesia strategy.5 Transverse thoracic muscle plane (TTP) block is a new perioperative analgesic method for post sternotomy discomfort. For patients undergoing heart surgery, TTP block offers sufficient postoperative pain control, resulting in lower pain scores, lower postoperative analgesic doses, shorter  extubation times, and shorter ICU stay lengths.6 TTP block reduces the perioperative  opioid consumption and  the incidence of nausea and vomiting.7,8 Lidocaine is a widely available and commonly used local anaesthetic. When administered intravenously it demonstrates anti hyperalgesic properties that improve acute postoperative pain management. Lignocaine also decreases the MAC (Minimal Alveolar Concentration) of volatile agents, reduces analgesic consumption and better analgesia.9 Lignocaine infusion for pain has been widely accepted and implemented in colorectal  ERAS protocol.10 Now it needs to be implemented in cardiac surgery for better analgesia. Similarly Dexmeditomedine  infusion provides better analgesia and reduces opioid  usage in the perioperative period.11 So, preoperative carbohydrate loading with opioid sparing multimodal analgesia improves outcome in patients undergoing cardiac surgery.