Enhanced Recovery After Cardiac Surgery (ERACS) has become the standard of care for selected patients. This study evaluated the evolution of the Leipzig concept in a specialized postanaesthesia care unit (PACU) over 15 years, with a focus on temporal trends and clinical outcomes.

A retrospective cohort study was conducted on patients admitted to PACU after cardiac surgery at the Heart Center Leipzig between November 2005 and December 2020. Postoperative outcomes, including postprocedural complications, hospital length of stay, delirium, and mortality, were recorded. The outcomes were analyzed via multivariable models, and the adjusted results are reported.

Among 56,371 cardiac surgery patients, 42% (n = 23,724) were admitted to the PACU and managed according to the ERACS protocol. After excluding incomplete datasets, 20,773 patients were analyzed. Utilization increased from 19% in 2006 to 60% in 2020. Despite a rising proportion of moderate- and high-complexity surgeries, in-hospital mortality has remained stable. Improved adherence to the ERACS components, including the integration of a delirium prevention bundle, was associated with significant reductions in postoperative delirium (p = 0.02) and in-hospital mortality (p = 0.007). Patients treated with sufentanil exhibited significantly lower in-hospital mortality than did those receiving remifentanil (p = 0.005). Subgroup analyses revealed higher in-hospital mortality in patients with EuroSCORE II ≥6%, complex procedures, and age ≥ 75 years (p < 0.001, p = 0.04, and p < 0.001, respectively).

This study presents the largest collection of consecutive ERACS patients ever collected and demonstrates the safety and efficacy of ERACS management with a specialized PACU, highlighting the benefits of continuous protocol optimization.