Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use

Chelsea M Loria; Kirsten Zborek; James B Millward; Matthew P Anderson; Cynthia M Richardson; Niharika Namburi; Zainab Faiza; Lava R Timsina; Lawrence S Lee

doi:10.1016/j.xjon.2022.08.008

Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use

JTCVS Open. 2022 Sep 6:12:280-296. doi: 10.1016/j.xjon.2022.08.008. eCollection 2022 Dec.

Authors

Chelsea M Loria¹, Kirsten Zborek¹, James B Millward¹, Matthew P Anderson¹, Cynthia M Richardson¹, Niharika Namburi¹, Zainab Faiza¹, Lava R Timsina¹, Lawrence S Lee^{1

2}

Affiliations

¹ Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Ind.
² Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Mass.

Abstract

Objective: Enhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia.

Methods: Single-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre-Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts.

Results: A total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre-Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history (P < .0001), endocarditis (P < .0001), and liver disease (P = .007) compared with the pre-Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre-Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre-Enhanced Recovery After Surgery group (P < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use.

Conclusions: Enhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.

Keywords: ERAS, Enhanced Recovery After Surgery; IVDU, intravenous drug use; MME, morphine milligram equivalent; NIVDU, nonintravenous drug use; NSAID, nonsteroidal anti-inflammatory drug; cardiac surgery; perioperative care.