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.