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. 2024 Sep 6:22:14-24.
doi: 10.1016/j.xjon.2024.08.018. eCollection 2024 Dec.

Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023

Alexander J Gregory  1 , Rakesh C Arora  2 , Subhasis Chatterjee  3 , Cheryl Crisafi  4 , Vicki Morton-Bailey  5 , Amanda Rea  6 , Rawn Salenger  7 , Daniel T Engelman  4 , Michael C Grant  8 ; ERAS Cardiac Working Group
Collaborators, Affiliations

Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023

Alexander J Gregory et al. JTCVS Open. .

Abstract

Objective: Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management.

Methods: Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.

Results: Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery.

Conclusions: There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.

Keywords: analgesia; comfort; enhanced recovery; multimodal analgesia; opioid; opioid-sparing; pain; perioperative care.

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Conflict of interest statement

A.J.G. reports speaker and advisory activities for Edwards Lifesciences. R.C.A. reports honoraria from Edwards Lifesciences and HLS Therapeutics. In addition, he functions on an Advisory Board for Renibus Therapeutics Inc. S.C. served on advisory boards for Edwards Lifesciences, La Jolla Pharmaceutical Company, Baxter Healthcare, and Eagle Pharmaceuticals. V.M.B. and A.R. report speaker's bureau, Edwards Lifesciences. R.S. reports consulting/advisory relationships with Zimmer Biomet, AtriCure, La Jolla, Terumo, Encare, and Edwards Lifesciences. D.T.E. reports Device Safety Monitoring Board: Edwards Lifesciences Transcatheter Valves, Trial Steering Committees: Renibus, Alexion, Cardiorenal Systems, Genentech; Medical Advisory Boards: Astellas, Medela, Arthrex, AtriCure. K.W.L reports consultant for Abiomed, Alexion, Medela, Medtronic, and Renibus. G.M. reports consultant for Edwards Lifesciences. S.R. reports advisor and speaker for 3M. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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ERAS Cardiac Society Turn Key Order Set for Multimodal Analgesia.
See this image and copyright information in PMC

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