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Featured Articles: Editorial

Enhanced Recovery After Cardiac Surgery: Are More (and Which) Opioid-Sparing Interventions Better?

Maldonado, Yasdet MD, MMM; Mehta, Anand R. MD; Skubas, Nikolaos J. MD

Author Information
doi: 10.1213/ANE.0000000000005238

See Article, p 1852

Enhanced recovery after cardiac surgery (ERACS) and opioid-sparing anesthetics are contemporary and complementary topics. These terms stem from work done in the early 1990s, when to optimize the expanding field of cardiac surgery and better match it with limited resources, “fast-track” cardiac anesthesia was born. It was based on a balanced anesthetic, comprised of a volatile agent and lower doses of opioids, aimed to primarily facilitate early tracheal extubation. At the same time, the concept of enhanced recovery after surgery (ERAS) was being applied in colorectal surgery. ERAS is a patient-centered process that employs multidisciplinary teamwork to achieve improved patient outcomes and decreased length of stay.1 The cumulative experience, in colorectal surgery and later other surgical specialties, lead to ERAS being widely accepted and practiced in noncardiac surgery.2 ERAS in cardiac surgery is nowadays being advocated as ERACS.3

Grant et al4 present findings from their own ERACS program in this issue of the Journal. It is a secondary analysis examining the association of nonopioid interventions on intraoperative opioid administration. The authors introduced and employed 5 nonopioid interventions: preoperative gabapentin and acetaminophen, intraoperative infusions of dexmedetomidine and ketamine, and regional anesthesia via a serratus anterior plane block. The choice and number of intervention(s) were left at the discretion of the anesthesiologist and intraoperative opioid dosing was discretionary. They report that an increasing number of any of the aformentioned interventions was associated with decreasing mean intraoperative opioid dosage (expressed in morphine sulfate equivalents [MSE]) as shown in their Figure 1. This decrease in intraoperative opioid dosage was not associated, however, with postoperative outcomes. In addition, no differences in postoperative pain scores, time to extubation, or length of stay were found when patients were stratified into low (≤50) versus high (>50) MSEs intraoperative opioid groups.

Looking back, anesthetic techniques for cardiac surgery were always opioid-based. High-dose opioid (morphine sulfate up to 3 mg/kg, equivalent to >20 µg/kg fentanyl) was introduced by Lowenstein et al5 in the 1960s and, later on, fentanyl at dosing of 25 µg/kg was advocated.6 In the current era, and more so during the times of the opioid epidemic and concern for chronic pain, low-dose fentanyl (<10 µg/kg) is common practice.7 The data related to multimodal nonopioid interventions in cardiac surgical patients are rather limited and only from selected interventions, such as coronary artery bypass surgery. Ketamine, the most frequently used nonopioid anesthetic, found its way into intraoperative regimens. However, the favorable profile of ketamine in noncardiac surgical patients was not mirrored in cardiac surgical patients.8 An increased incidence of hallucinations and nightmares was found in older patients treated with higher doses of ketamine without a decrease in chronic pain.9 Perioperative gabapentinoids also failed to meet the expectations of reducing postoperative acute pain, as shown in a recent systematic review.10 On the other hand, dexmedetomidine has shown promising results in decreasing delirium and length of stay after cardiac surgery at the expense of the occurrence of bradycardia.11,12 Acetaminophen, which is costly in intravenous form, has an analgesic effect but does not decrease mean opioid consumption or persistent surgical pain in patients recovering from median sternotomy.13,14 Finally, a serratus anterior block has been shown to decrease pain but not opioid consumption in minimally invasive thoracic surgery.15

Another finding of the Grant et al4 study is that adoption of their nonopioid interventions was orchestrated over a period of time (Figure 3), and it was not fully embraced by all clinicians. In 22% of their patients, no intervention was applied, while only 3% of the patients received all 5 nonopioid interventions. Their study reflects common clinical practices and illustrates that adoption of change takes time and hard work. As the authors point out, this was a post hoc analysis, and selection bias, provider’s preferences, and other confounders should be considered when interpreting the results.

ERACS is a contemporary subject. The scientific group promoting the topic ( provides recommendations that are based on experts’ opinions, not on high-quality, prospective, randomized studies.3 Which raises the issue: what is ERACS and what are its worthy goals? ERACS should be a patient-centered, system-wide process that spans the entire perioperative patient experience. More notable, opioid-sparing pain management plans is but one of many initiatives aimed at improving outcomes and decreasing length of stay.

As limited as Grant et al’s4 study may be, it is a great starting point. It shows what is feasible, at least as a concept, and points out some of the challenges when changing clinical practices. It remains unproven whether multimodal nonopioid interventions will have the desired effect in our patients’ journeys. It will be up to our future collaborations to find out. The time is now.


Name: Yasdet Maldonado, MD, MMM.

Contribution: This author assisted in manuscript drafting, key revision, and final manuscript approval.

Name: Anand R. Mehta, MD.

Contribution: This author assisted in manuscript drafting, key revision, and final manuscript approval.

Name: Nikolaos J. Skubas, MD.

Contribution: This author assisted in manuscript drafting, key revision, and final manuscript approval.

This manuscript was handled by: Stefan G. De Hert, MD.


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