Cardiac ERAS Studies: Importance of Blinding

Administering Norepinephrine Peripherally Is Safe, as Long as There Is No IV Extravasation

“…(ERP-CS). 3 In their letter, Markham et al 1 rightfully highlight that any formal multimodal analgesia plan ought to be initiated preoperatively and administered throughout all phases of the perioperative encounter. Our program, implemented in full since the completion of the study period, includes the scheduled administration of oral acetaminophen and gabapentin (adjusted for relevant patient-related factors including age, renal, and liver function) for 5 days after surgery, the preference for and continuation of dexmedetomidine (rather than propofol) for postoperative sedation and the targeted adjunctive use of ketamine in subhypnotic doses in the postoperative period, particularly for those patients with opioid tolerance.…”

In Response

“…Our team appreciates the opportunity to respond to the thoughtful letter submitted by Dr Markham et al 1 regarding our recent publication, 2 which involved a secondary analysis of the immediate preoperative and intraoperative phases of the staged implementation of an institutional enhanced recovery program for cardiac surgery (ERP-CS). 3 In their letter, Markham et al 1 rightfully highlight that any formal multimodal analgesia plan ought to be initiated preoperatively and administered throughout all phases of the perioperative encounter.…”

“…Our team appreciates the opportunity to respond to the thoughtful letter submitted by Dr Markham et al 1 regarding our recent publication, 2 which involved a secondary analysis of the immediate preoperative and intraoperative phases of the staged implementation of an institutional enhanced recovery program for cardiac surgery (ERP-CS). 3 In their letter, Markham et al 1 rightfully highlight that any formal multimodal analgesia plan ought to be initiated preoperatively and administered throughout all phases of the perioperative encounter. Our program, implemented in full since the completion of the study period, includes the scheduled administration of oral acetaminophen and gabapentin (adjusted for relevant patient-related factors including age, renal, and liver function) for 5 days after surgery, the preference for and continuation of dexmedetomidine (rather than propofol) for postoperative sedation and the targeted adjunctive use of ketamine in subhypnotic doses in the postoperative period, particularly for those patients with opioid tolerance.…”

“…This strategy did not suggest harm, as lower opioids were not associated with worse postoperative pain or poorer clinical outcomes. Markham et al 1 assert that relying on noxious stimuli to titrate opioids is insufficient, citing opportunities to evaluate markers of inflammation or surgical stress as a viable alternative. This recapitulates a long-debated controversy as to how best to prevent, interpret, and manage pain in patients undergoing general anesthesia.…”