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FloTrac-Guided Hemodynamic Monitoring Optimizes ERAS Implementation in Coronary Artery Bypass Surgery: A
Joy Wang1, Kartik S Akkihal1, Daniela Lopez1
1Texas A&M University Naresh K. Vashisht College of Medicine, Dallas, TX.
Background:
Enhanced Recovery After Surgery (ERAS) has been shown to reduce perioperative complications, shorten intensive care unit (ICU) length of stay, and facilitate faster extubation in cardiac surgery patients, though the implementation benefits remains understudied. The role of continuous hemodynamic monitoring in optimizing ERAS for cardiac surgery has not been well established. This study evaluates the impact of ERAS implementation on cardiovascular patients undergoing elective isolated coronary artery bypass grafting (ISO-CABG).
Methods:
Retrospective analysis of prospectively collected data from 380 patients undergoing elective ISO-CABG (January-December 2024) stratified into: pre-ERAS (phase 1, n = 238), ERAS without hemodynamic monitoring (phase 2, n = 119), and ERAS with FloTrac-guided monitoring (phase 3, n = 23). Primary outcomes included extubation time and ICU length of stay. CABG (January-December 2024) stratified into preextubation time was analyzed using both mean and median values to account for variability in distribution. Secondary outcomes included hypotension duration, area under threshold (mmHg*min), and time-weighted average at mean arterial pressure <65 mmHg.
Results:
Mean extubation time decreased across phases: phase 1: 10 hours 17 minutes (SD 4.5), phase 2: 9 hours 27 minutes (SD 5.2), and phase 3: 5 hours 54 minutes (SD 3.0). Median extubation time similarly decreased (phase 1: 10:47 hours, phase 2: 9:05 hours, phase 3: 4:26 hours), with phase 3 significantly shorter than phase 2 (p = 0.018). Phase 3 demonstrated a 43% reduction in mean extubation time compared to phase 1 (95% CI -6.26 to -2.50 hours; p < 0.001). ICU length of stay showed a non-linear pattern: phase 1: 34:52 hours (SD 12.0), phase 2: 41:27 hours (SD 18.0), and phase 3: 32:58 hours (SD 13.0). Phase 3 was not significantly different from phase 1 (p = 0.472) but was significantly shorter than phase 2 (p = 0.033). Hypotension duration decreased across phases: phase 1: 47.7 minutes (SD 146.1), phase 2: 50.6 minutes (SD 74.1), phase 3: 13.6 minutes (SD 19.5), representing a 74% reduction from phase 1 to phase 3 (95% CI -45.2 to -30.2 minutes; p < 0.001). AUT decreased from 218 (phase 1) to 260 (phase 2) to 88 (phase 3) (p = 0.006), and TWA decreased from 0.33 (phase 1) to 0.24 (phase 2) to 0.07 (phase 3) (p < 0.001).
Conclusion:
ERAS implementation was associated with modest improvements in extubation time, while full protocol integration with hemodynamic monitoring (phase 3) demonstrated the most favorable outcomes in extubation time and perioperative hemodynamic stability. The observed improvements likely reflect a combination of increased ERAS protocol adherence, workflow optimization, and real-time hemodynamic feedback, rather than the isolated effect of FloTrac monitoring alone. Active clinician engagement with physiologic data appears essential to optimize perioperative outcomes in ISO-CABG patients.
