Introduction
Enhanced recovery after surgery (ERAS) protocols are being used in
various surgical areas in an effort to reduce the use of opioids while
responding to the trauma of surgery and postoperative pain. This has
become increasingly important in the wake of the opioid crisis and the
confirmed role that surgeons can play . [1-3] Cardiac surgeons are
not without fault in this crisis, with some studies demonstrating that
nearly 10% of cardiac surgery patients go on to develop persistent
opioid requirements after cardiac surgery [4] Indeed, ERAS protocols
are highlighted for their pain managements strategies which the do not
rely on opioids, but the benefits extend beyond pain management. These
protocols have demonstrated improvement in length of stay and overall
postoperative complications in multiple surgical specialties.[5,6]
Hirji et al developed a list of objective data elements which could be
collected to demonstrate the benefits of ERAS protocols for cardiac
surgery and standardize benchmarks across hospitals.[7] A brief
commentary noted the benefits of ERAS protocols for cardiac surgery with
early extubation, potentially even in in the operating room immediately
after surgery.[8] Williams et al noted in a 1-year study that ERAS
protocols for cardiac surgery programs had significantly improved
perioperative outcomes including decreased intensive care unit (ICU)
stay and hospital length of stay (LOS), decreased incidence of
gastrointestinal (GI) complications, and decreased utilization of
narcotic pain regimens.[9] Pain management and opioid sparing
strategies are only a portion of a comprehensive ERAS protocol. The
benefits of these protocols go beyond pain control and are
multi-dimensional in their aim to improve the patients’ surgical
experience. Adequate pain control may lead to patient satisfaction,
overall improved attitude towards the postoperative experience, and
increased willingness to participate in postoperative care (eg, physical
therapy etc). Currently, the ERAS studies in cardiac surgery have
focused on many aspects of improving the postoperative course of
patients, including faster time to extubation, decreased length of stay,
and others. We developed an ERAS protocol as a quality improvement
initiative and sought to evaluate its effect regarding pain control. We
hypothesized that with a multi-modality pain regimen and limited
narcotics administration, patients’ pain would be well controlled after
cardiac surgery, resulting in improved patient satisfaction.