Cardiac Enhanced Recovery Program Implementation and Its Effect on Opioid Administration in Adult Cardiac Surgery

      In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P < 0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes.



      ERAS (enhanced recovery after surgery), t-ERAS (transition to enhanced recovery after surgery), LOS (length of stay), STS (Society of Thoracic Surgeons), CABG (coronary artery bypass grafting), MME (morphine milligram equivalents), NSAID (non-steroidal anti-inflammatory drugs), POD (postoperative Day), ICU (intensive care unit)
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        • Martin L.W.
        • Sarosiek B.M.
        • Harrison M.A.
        • et al.
        Implementing a thoracic enhanced recovery program: Lessons learned in the first year.
        Ann Thorac Surg. 2018; 105: 1597-1604
        • Modesitt S.C.
        • Sarosiek B.M.
        • Trowbridge E.R.
        • et al.
        Enhanced recovery implementation in major gynecologic surgeries: Effect of care standardization.
        Obstet Gynecol. 2016; 128: 457-466
        • Thiele R.H.
        • Rea K.M.
        • Turrentine F.E.
        • et al.
        Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.
        J Am Coll Surg. 2015; 220: 430-443
        • Noss C.
        • Prusinkiewicz C.
        • Nelson G.
        • et al.
        Enhanced recovery for cardiac surgery.
        J Cardiothorac Vasc Anesth. 2018; 32: 2760-2770
        • Fleming I.O.
        • Garratt C.
        • Guha R.
        • et al.
        Aggregation of marginal gains in cardiac surgery: Feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients.
        J Cardiothorac Vasc Anesth. 2016; 30: 665-670
        • Sola M.
        • Ramm C.J.
        • Kolarczyk L.M.
        • et al.
        Application of a multidisciplinary enhanced recovery after surgery pathway to improve patient outcomes after transcatheter aortic valve implantation.
        Am J Cardiol. 2016; 118: 418-423
        • Williams J.B.
        • McConnell G.
        • Allender J.E.
        • et al.
        One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program.
        J Thorac Cardiovasc Surg. 2018; : 1881-1888
        • Engelman D.T.
        • Ben Ali W.
        • Williams J.B.
        • et al.
        Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations.
        JAMA Surg. 2019; : 755-766
        • Bruera E.
        Parenteral opioid shortage - Treating pain during the opioid-overdose epidemic.
        N Engl J Med. 2018; 379: 3
        • Rudd R.A.S.P.
        • David F.
        • Scholl L.
        Increases in drug and opioid-involved overdose deaths — United States, 2010–2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 8
        • Callinan C.E.
        • Neuman M.D.
        • Lacy K.E.
        • et al.
        The initiation of chronic opioids: A survey of chronic pain patients.
        J Pain. 2017; 18: 360-365
        • Hollingsworth H.
        • Herndon C.
        The parenteral opioid shortage: Causes and solutions.
        J Opioid Manag. 2018; 14: 81-82
        • Hayhurst C.J.
        • Durieux M.E.
        Differential opioid tolerance and opioid-induced hyperalgesia: A clinical reality.
        Anesthesiology. 2016; 124: 483-488
        • Fechner J.
        • Ihmsen H.
        • Schuttler J.
        • et al.
        The impact of intra-operative sufentanil dosing on post-operative pain, hyperalgesia and morphine consumption after cardiac surgery.
        Eur J Pain. 2013; 17: 562-570
        • van Gulik L.
        • Ahlers S.J.
        • van de Garde E.M.
        • et al.
        Remifentanil during cardiac surgery is associated with chronic thoracic pain 1 yr after sternotomy.
        Br J Anaesth. 2012; 109: 616-622
        • Murphy G.S.S.J.
        • Avram M.J.
        • Greenberg S.B.
        • et al.
        Intraoperative methadone for the prevention of postoperative pain - A randomized, double-blinded clinical trial in cardiac surgical patients.
        ANESTHESIOLOGY. 2015; 122: 10
        • Noss C.
        • Anderson K.J.
        • Gregory A.J.
        Erector spinae plane block for open-heart surgery: A potential tool for improved analgesia.
        J Cardiothorac Vasc Anesth. 2019; 33: 376-377
        • Yeung J.H.
        • Gates S.
        • Naidu B.V.
        • et al.
        Paravertebral block versus thoracic epidural for patients undergoing thoracotomy.
        Cochrane Database Syst Rev. 2016; 2CD009121
        • Al-Attar N.
        • Morcos K.
        • Mahmood Z.
        High infection rates after ropivacaine infusion in the median sternotomy incision following cardiac surgery.
        Reg Anesth Pain Med. 2013; 38: 371-372
        • Hudetz J.A.
        • Patterson K.M.
        • Iqbal Z.
        • et al.
        Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass.
        J Cardiothorac Vasc Anesth. 2009; 23: 651-657
        • Djaiani G.S.N.
        • Fedorko L.
        • Carroll J.
        • et al.
        Dexmedetomidine versus propofol sedation reduces delirium after cardiac surgery: A randomized controlled trial.
        Anesthesiology. 2016; 124: 6
        • Allen K.B.
        • Icke K.J.
        • Thourani V.H.
        • et al.
        Sternotomy closure using rigid plate fixation: A paradigm shift from wire cerclage.
        Ann Cardiothorac Surg. 2018; 7: 611-620
        • Grauhan O.
        • Navasardyan A.
        • Tutkun B.
        • et al.
        Effect of surgical incision management on wound infections in a poststernotomy patient population.
        Int Wound J. 2014; 11: 6-9
        • Kowalewski M.
        • Raffa G.M.
        • Szwed K.A.
        • et al.
        Meta-analysis to assess the effectiveness of topically used vancomycin in reducing sternal wound infections after cardiac surgery.
        J Thorac Cardiovasc Surg. 2017; 154: 1320-1323.e1323
        • Investigators N.S.S.
        Intensive versus conventional glucose control in critically ill patients.
        New Engl J Med. 2009; 360: 14
        • Bhamidipati C.M.
        • LaPar D.J.
        • Stukenborg G.J.
        • et al.
        Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2011; 141: 543-551
        • Li M.
        • Zhang J.
        • Gan T.J.
        • et al.
        Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: A randomized clinical trial.
        Eur J Cardiothorac Surg. 2018; 54: 491-497
        • Thiels C.A.
        • Habermann E.B.
        • Hooten W.M.
        • et al.
        Chronic use of tramadol after acute pain episode: Cohort study.
        BMJ. 2019; 365: l1849
        • Ljungqvist O.
        • Scott M.
        • Fearon K.C.
        Enhanced recovery after surgery: A review.
        JAMA Surg. 2017; 152: 292-298
        • Khwaja A.
        KDIGO clinical practice guidelines for acute kidney injury.
        Nephron Clin Pract. 2012; 120: c179-c184