Regional anesthesia in cardiac surgery: from an adjunct technique to a key component of the ERAS strategy

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Abstract
The historical paradigm of cardiac anesthesia, reliant on high-dose opioids, carries inherent risks of prolonged mechanical ventilation, increased complications, and extended hospital stays. The contemporary shift towards minimally invasive surgery and the widespread adoption of Enhanced Recovery After Surgery (ERAS) protocols necessitates a move from deep sedation towards the active control of the perioperative stress response, thereby redefining the role of regional anesthesia (RA). This review aims to provide a detailed analysis of the evolution, evidence base, and clinical significance of regional anesthesia techniques within multimodal ERAS strategies in cardiac anesthesia practice. A systematic literature search was conducted following PRISMA guidelines across PubMed/MEDLINE, Embase, Cochrane CENTRAL, and other databases (January 2000 — March 2025). After a two-stage screening process, 46 publications were included for final analysis. Due to significant clinical heterogeneity among the studies, a structured narrative synthesis was performed. The results show that regional anesthesia has evolved from an adjunct analgesic technique into a strategic pillar of anesthetic management. Its fundamental advantage — the preemptive blockade of nociceptive afferentation — enables effective modulation of the surgical stress response. The integration of RA into ERAS protocols demonstrably promotes hemodynamic stability, reduces pulmonary complications, provides effective analgesia with minimal opioid use, shortens extubation time and ICU stay, and ultimately accelerates functional patient recovery. Thus, regional anesthesia serves as a cornerstone of modern multimodal cardiac anesthesia aligned with the ERAS philosophy, and the proactive use of contemporary ultrasound-guided RA techniques is helping to establish a new standard of care focused on improving perioperative outcomes, patient safety, and quality of life following cardiac surgery.

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