Conclusions
Despite lacking statistical significance, our data suggest an overall reduction in reported symptoms associated with the ERAS protocol at hospital discharge, compared to ICU transfer (Table 3 ; 10/16 ORs < 1). Conversely, the data also suggest an overall increase in symptom reporting associated with the ERAS protocol at the 2-week outpatient visit, compared to hospital discharge (Table 3 ; 14/16 ORs >1). The notable exception to this was the odds of reporting severe pain at the 2 weeks follow up vs. hospital discharge (p=0.075). However, this relationship can be partially explained by the very low reporting of severe pain at hospital discharge for the ERAS group. In our sample, patients rarely reported any outcome with frequency beyond “some of the time”.
Surgeons have proven to be high opioid prescribers, and previously there was limited evidence to support discrete recommendations [11-13]. In general however, surgeons have been found to be over-prescribers of opioid pain medications [11]. This has prompted the proliferation and study of protocols which minimize narcotic pain medications. Few studies in the cardiothoracic literature have specifically addressed the influence of pain medication regimens, and adequacy of pain control on patient satisfaction with an ERAS protocol. Wagner et al performed a multicenter retrospective analysis on patient undergoing CABG and identified that in their study 28% of opioid naïve patients could be discharged without an opioid prescription and the vast majority of these never required an opioid prescription at follow-up [14]. Pan et al evaluated patients’ satisfaction after elective cesarean section.[15] The study noted that patients who were treated with an ERAS protocol reported a decreased incidence of intraoperative nausea, decreased pain scores during the first 24 hours at rest, and during motion in the first 24 hours and 48 hours after surgery. They also reported that patient satisfaction was higher in the ERAS group. Li et al published a review article on the use of ERAS protocols in colorectal surgery.[16] Four of the 15 publications discussed patient satisfaction with the use of an ERAS protocol. There was no difference in patient satisfaction in 2 of these studies. Just one study noted an improvement in overall patient satisfaction scores. Li et al concluded that patient satisfaction was not worse with an ERAS protocol, which is similar to the results of our study. Debono et al noted the use of an ERAS protocol in spine surgery, specifically spine fusion surgery.[17] The study noted, based on a 5-point Likert scale, that 86.5% of patients were satisfied or very satisfied with overall care. Rege et al also noted improved pain scores with an ERAS protocol in laparoscopic donor nephrectomy.[18] Echeverria-Villabolos et al conducted a study to evaluate ERAS protocol to reduce postoperative opioid use.[19] The study noted that an effective multi-modality pain regimen that was narcotic-free, including medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin, regional anesthetic medications, etc, was associated with decreased narcotic use in the postoperative setting.
Limited studies exist that evaluate patient satisfaction in the postoperative environment with regard to pain control in all of the surgical literature. This study evaluates the use of a multi-modality minimal narcotic pain regimen for cardiac surgery patients. When compared to a more traditional narcotic based pain regimen, patients’ satisfaction demonstrated no difference. This study emphasizes in addition to other ERAS studies in cardiac surgery, that patients’ recovery quality can be maintained and potentially benefit from a minimal narcotic regimen.
There are some limitations in our study to consider. The analysis sample was recruited via mutually exclusive pre-defined recruitment windows for each treatment group, potentially contributing to some degree of bias among the study characteristics between the treatment groups. The limited time window for data collection paired with the patient throughput restricted the sample further than desired leaving some potentially clinically meaningfully differences undetected.
Future studies would benefit from additional assessment for pain intensity, such as the visual analogue scale (VAS) or the numeric rating scale (NRS). Subgroup analyses for surgical approach would uncover potential confounders to the performative evaluation of the ERAS protocol.
In conclusion, we have demonstrated the potential for the ERAS protocol to provide equivalent pain and psychological outcomes compared to PRN opioids for cardiac surgery patients. These results need to be confirmed with rigorously designed randomized clinical trials, including multiple sites and increased patient recruitment. With the potential to drastically reduce the amount of opioids in the community, this research should be a high priority.