No Decrease in Opioid Consumption With Multimodal Analgesia For Cardiac Surgery

After undergoing cardiac surgery, patients who received multimodal analgesia (MMA) were more likely to be mobile within 1 day of surgery, but they did not have lower opioid consumption compared with patients who received opioid-based analgesia, according to results of a study published in the Journal of Cardiothoracic Surgery.

Within a multicenter healthcare system in the United States, 2 cardiothoracic surgery intensive care units (ICUs) implemented a postoperative MMA policy involving a combination of drug therapy and/or therapeutic techniques to align with Enhanced Recovery After Surgery (ERAS) recommendations from the Cardiac Society and 1 unit continued using established protocols. The study authors commented, “We hypothesized that a MMA pathway would reduce opioid consumption and opioid-related postoperative complications compared to opioid-based pain management.”

Electronic medical records collected between 2018 and 2019 from the 3 units were reviewed, and patient outcomes following conventional coronary artery bypass grafting (CABG) and/or valve surgery were evaluated on the basis of whether patients received MMA-based (n=383) or opioid-based (n=379) postsurgical pain management.

The mean ages of patients in the MMA and control cohorts were 64 (interquartile range [IQR], 57-71) and 66 (IQR, 59-72) years, 30% and 20.6% were women (P =.0035), 59% and 69% were White (P =.0017), mean body mass index (BMI) values were 29.2 (IQR, 26.1-33.3) and 27.7 (IQR, 25.0-31.7) kg/m² (P =.0006), and 68% and 84% underwent CABG (P <.0001), respectively.

Patients in the MMA group received higher doses of opioids than those in the control group (P <.0009); however, the significant difference was attenuated after adjusting for fentanyl use. A total of 10.7% of patients in the MMA group and 0.5% of patients in the comparator group received at least 1000 mcg fentanyl with at least 500 mg morphine milligram equivalents (MMEs). The median fentanyl dose was 50 mcg for patients in the MMA cohort compared with 0 for patients in the control group.

After adjusting for prolonged ventilation postoperatively, participants in the MMA group were more likely to ambulate within 1 day following surgery (adjusted odds ratio [aOR], 0.44; 95% CI, 0.31-0.63; P <.0001) compared with participants in the control group.

However, participant in the MMA group were more likely to have a first postoperative bowel movement at 4 to 9 days compared with at days 0 to 3 for participants in the control group (aOR, 1.93; 95% CI, 1.30-2.87; P =.0011). Participants in the MMA group also required more time to achieve a 0 Richmond Agitation-Sedation Scale (RASS) score compared with participants in the control group (aOR, 1.62; 95% CI, 1.15-2.29; P =.0071).

In general, ICU length of stay was predicted by ethnicity (P =.0002), use of psychotropic agents (P =.001), and number of adjunct medications received (P =.011).

This study may have been limited as the comparator group was sourced from a separate cardiothoracic surgery ICU.

Study authors conclude that implementation of the MMA policy to manage pain experienced by patients following CAGB and/or valve surgery pain resulted in decreased time to ambulation but increased time to first bowel movement and a RASS score of 0. The MMA strategy did not decrease opioid consumption and increased use of fentanyl. These findings do not support the MMA-based strategy for reducing opioid consumption in the postcardiac surgery setting.