Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

Grant, Michael C.; Chappell, Desiree; Gan, T. J.; Manning, Michael W.; Miller, Timothy E.; Brodt, Jessica; Shaw, Andrew; Engelman, Daniel; Mythen, Michael G.; Guinn, Nicole R.; Aronson, Solomon; Schwartz, Joseph B.; Arora, Rakesh C.; Morton-Bailey, Vicky; Brudney, Charles S.; Bennett‐Guerrero, Elliott; Reddy, V. Seenu; Guzzi, Lou; Brown, J.; Crisafi, Cheryl

doi:10.1016/j.jtcvs.2023.01.020

Cited by 17 publications

(12 citation statements)

References 81 publications

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“…Opioid stewardship involves the judicious use of opioids, balancing the benefits of optimal analgesia against the side effects and risk of opioid use (Grant et al, 2023). The opposite, overprescription, is an inherent problem in the United States.…”

Section: Problem Descriptionmentioning

confidence: 99%

“…Gabapentinoids alone could increase sedation without significantly reducing pain (Maitra et al, 2017). Nonsteroidal anti-inflammatory drugs are not included regularly in enhanced recovery after surgery (ERAS) guidelines for CVS because of the potential risk of acute kidney injury (Engelman et al, 2019;Grant et al, 2023). Multimodal analgesia can also improve other symptoms, such as nausea, without increasing adverse outcomes (Salenger et al, 2022).…”

Section: Available Knowledgementioning

confidence: 99%

“…Acetaminophen has been used extensively in most ERAS projects with excellent outcomes, and it is a safe first option in the multimodal arsenal (Salenger et al, 2022). Different pain management guidelines recommend acetaminophen postoperatively and after discharge (Chou et al, 2016;Clarke et al, 2020;Grant et al, 2023). However, these new approaches have not been adopted broadly (Brescia et al, 2021).…”

Section: Available Knowledgementioning

confidence: 99%

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Implementing an evidence-based guideline to decrease opioids after cardiac surgery

Galao-Malo,

Davidson,

D'Aoust

et al. 2024

J Am Assoc Nurse Pract

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Background: Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem. Local problem: There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented. Methods: This is a single-center, pre–post quality improvement project in adult patients after elective cardiac surgery through sternotomy. Interventions: Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge. Results: The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% (p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% (p < .001) and with 25 or less MME from 30% to 55% (p < .01). Acetaminophen prescription at discharge increased from 10% to 48% (p < .001). Conclusions: Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.

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Section: Problem Descriptionmentioning

confidence: 99%

Section: Available Knowledgementioning

confidence: 99%

Section: Available Knowledgementioning

confidence: 99%

See 1 more Smart Citation

Implementing an evidence-based guideline to decrease opioids after cardiac surgery

Galao-Malo,

Davidson,

D'Aoust

et al. 2024

J Am Assoc Nurse Pract

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“…Additionally, little is known about the impact of ERAS protocols survival or major cardiovascular events, and the heterogeneity of the observational evidence further reduces the understanding of the ERAS effect on outcomes. Importantly, the entirety of the ERAS measures and pathway, as recently systematized in guidelines 1 and consensus statements, 5 have not been captured in the published studies, and the available literature actually focuses on “ERAS‐like” protocols or only limited number of ERAS measures.…”

Section: Introductionmentioning

confidence: 99%

Enhanced recovery protocols after surgery: A systematic review and meta‐analysis of randomized trials in cardiac surgery

Spadaccio,

Salsano,

Pisani

et al. 2024

World j. surg.

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BackgroundPrevious meta‐analyses combining randomized and observational evidence in cardiac surgery have shown positive impact of enhanced recovery protocols after surgery (ERAS) on postoperative outcomes. However, definitive data based on randomized studies are missing, and the entirety of the ERAS measures and pathway, as recently systematized in guidelines and consensus statements, have not been captured in the published studies. The available literature actually focuses on “ERAS‐like” protocols or only limited number of ERAS measures. This study aims at analyzing all randomized studies applying ERAS‐like protocols in cardiac surgery for perioperative outcomes.MethodsA meta‐analysis of randomized controlled trials (RCTs) comparing ERAS‐like with standard protocols of perioperative care was performed (PROSPERO registration CRD42021283765). PRISMA guidelines were used for abstracting and assessing data.ResultsThirteen single center RCTs (N = 1704, 850 in ERAS‐like protocol and 854 in the standard care group) were selected. The most common procedures were surgical revascularization (66.3%) and valvular surgery (24.9%). No difference was found in the incidence of inhospital mortality between the ERAS and standard treatment group (risk ratio [RR] 0.61 [0.31; 1.20], p = 0.15). ERAS was associated with reduced intensive care unit (standardized mean difference [SMD] −0.57, p < 0.01) and hospital stay (SMD −0.23, p < 0.01) and reduced rates of overall complications when compared to the standard protocol (RR 0.60, p < 0.01) driven by the reduction in stroke (RR 0.29 [0.13; 0.62], p < 0.01). A significant heterogeneity in terms of the elements of the ERAS protocol included in the studies was observed.ConclusionsERAS‐like protocols have no impact on short‐term survival after cardiac surgery but allows for a faster hospital discharge while potentially reducing surgical complications. However, this study highlights a significant nonadherence and heterogeneity to the entirety of ERAS protocols warranting further RCTs in this field including a greater number of elements of the framework.

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“…ERAS has numerous advantages when compared with traditional perioperative measures [ 1 , 2 ]. Several studies have demonstrated that ERAS is effective in reducing hospitalization costs and shortening the hospital stay without increasing the incidence of postoperative complications, readmissions, or mortality [ 3 , 4 ]. Furthermore, ERAS has been shown to improve the 5-year survival rate of patients undergoing various types of general surgery, including colorectal surgery and gastrectomy [ 5 , 6 ].…”

Section: Introductionmentioning

confidence: 99%

Value of enhanced recovery after surgery in patients undergoing endoscopic retrograde cholangiopancreatography with intravenous anaesthesia for choledocholithiasis: a retrospective observational study.

Lyu,

Wang,

et al. 2023

Videosurgery and Other Miniinvasive Techniques

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Introduction Enhanced recovery after surgery (ERAS) is rarely used in minimally invasive endoscopic surgery, especially in endoscopic retrograde cholangiopancreatography (ERCP). Aim This study evaluated the safety and efficacy of the ERAS protocol in patients undergoing ERCP for choledocholithiasis. Material and methods The study had a retrospective design and included patients with biliary tract stones who underwent ERCP between June 2019 and November 2022. Patients who received the ERAS protocol between June 2021 and November 2022 were enrolled as an ERAS group, and those who received traditional perioperative treatment between December 2019 and May 2021 were enrolled as a control group. Results A total of 349 patients were enrolled (ERAS group, n = 185; control group, n = 164). The cannulation and stone extraction success rates were significantly higher in the ERAS group than in the control group (p < 0.05). The incidence of postoperative pancreatitis was significantly lower in the ERAS group (p = 0.02), but there were no significant differences in other complications. The postoperative hospital stay was significantly shorter in the ERAS group than in the control group (p < 0.001), with no statistically significant differences in costs according to surgical period, or in total costs, between the 2 groups. Conclusions Application of the ERAS protocol is safe and feasible in patients undergoing ERCP for choledocholithiasis. The ERAS protocol can accelerate recovery, reduce postoperative pain, and shorten the hospital stay without increasing the cost of treatment.

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Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

Cited by 17 publications

References 81 publications

Implementing an evidence-based guideline to decrease opioids after cardiac surgery

Implementing an evidence-based guideline to decrease opioids after cardiac surgery

Enhanced recovery protocols after surgery: A systematic review and meta‐analysis of randomized trials in cardiac surgery

Value of enhanced recovery after surgery in patients undergoing endoscopic retrograde cholangiopancreatography with intravenous anaesthesia for choledocholithiasis: a retrospective observational study.

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