The Impact of Robotic versus Conventional Coronary Artery Bypass Grafting on In-Hospital Narcotic Use: A Propensity-Matched Analysis

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> The aim of this study was to compare narcotic use in the perioperative hospital stay as a measure of pain in patients undergoing robotic versus conventional coronary artery bypass grafting (CABG). </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> Propensity score matching of patients undergoing robotically assisted CABG and conventional CABG over a period of 5 years was performed. A retrospective chart review was performed to identify the total amount of narcotics used by both groups calculated as morphine equivalent dosing (MED). </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> From 2007 to 2012, 154 patients underwent robotic CABG, and 1660 underwent conventional CABG. Propensity matching resulted in 142 patients in each group. Patients undergoing robotic CABG received less blood transfusion, were more frequently extubated in the operating room, and had a shorter length of stay. The robotic group had a lower MED than the conventional group as defined by the primary end point[181 (11) vs 251 (8)]. If intraoperative narcotic use was eliminated, there was no difference in MED from postoperative days 0 to 3. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Patients undergoing robotic CABG use fewer narcotics over the first three hospital days than patients undergoing conventional CABG. The surrogate of narcotics use for postoperative pain shows that the minithoracotomy of robotic CABG may result in either less or equivalent pain than the sternotomy of conventional CABG. </jats:p></jats:sec>

Users’ guide to the surgical literature: how to assess an article using surrogate end points

“…In this section, we will determine whether narcotics use as a surrogate for postoperative pain satisfies the criteria proposed by Prentice 4 Turning to the study by Raad and colleagues, 13 our goal is to assess the strength of the association between narcotic use (surrogate end point) and postoperative pain (target outcome) to establish causality. To do this, we must once again look in the literature and find a biological basis for postoperative opioid analgesia as well as present evidence of a correlation between the quantity of opioid use and pain severity.…”

“…Before one can confidently accept the results of an intervention and make recommendations to patients on the basis of a surrogate end point measure, a strong relationship with the target outcome must be documented across RCTs. 2,6 The study by Raad and colleagues 13 does not provide direct reference to an RCT showing the validity of narcotic use as a surrogate end point for postoperative pain. In this case, we must once again refer to the literature for evidence.…”

“…In the study by Raad and colleagues, 13 reference is made to a study by Bucerius and colleagues, 25 which assessed postoperative pain in patients undergoing robotic, minimally invasive direct coronary artery bypass (MIDCAB), and conventional CABG procedures. This semirandomized trial prospectively followed 190 patients and concluded that the robotic group experienced a significant reduction in postoperative pain and required fewer opioid analgesics, despite not reaching statistical significance.…”

“…The remaining article is a retrospective propensitymatched analysis published in 2016. 13 You determine that this is the only article assessing robotic versus conventional CABG to reference narcotic consumption as a surrogate end point for postoperative pain and thus adequately addresses the question posed in the clinical scenario. You ultimately decide to critically review this article by Raad and colleagues.…”

“…You ultimately decide to critically review this article by Raad and colleagues. 13 The characteristics of their study are outlined in Table 1.…”