Is It Time for Paradigm Shift in Pain Management for Cardiac Surgery Patients?

Opioids are reliable and effective analgesics for treating acute postoperative pain following any surgical procedure, including cardiac surgery. Recent concerns about persistent opioid use after discharge from the hospital have triggered changes in the way patients’ pain is managed during their perioperative period. This has led to the widespread use of various regional analgesic techniques, as well as anesthesia techniques based on non-narcotic analgesics for cardiac surgery. Multi-modal analgesia has been an accepted component of enhanced recovery after surgery (ERAS) protocols and implementation of ERAS in cardiac surgery has been shown to decrease opioid consumption, duration of mechanical ventilation, and length of intensive care unit and hospital stay. Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) invited submissions related to painmanagement after cardiac surgery and published a series of impressive articles dedicated to this important topic for the December issue. Devarajan et al explored evidence behind the use of various neuraxial and non-neuraxial regional analgesic techniques in a two-part review. It is clear that epidural blocks will not be re-entering the cardiac surgical arena because of concerns over epidural hematoma, despite their advantages. However, spinal opioids are making a comeback, with renewed interest in their clinical use and research for ERAS protocols. Tissue plane blocks (erector spinae block, pecto-intercostal block, and transverse thoracic plane block) are becoming popular, as they can be administered easily with ultrasound guidance and have been found to be safe compared to central neuraxial blocks in cardiac surgery. In this issue of SCVA, two original articles are published on the use of these tissue plane blocks in cardiothoracic surgery. Cardinale et al studied transverse thoracic plane blocks in elective cardiac surgery along with multimodal analgesia. The authors reported increased early extubations and shortened length of intensive care unit and hospital stay. Dunham et al published on the utility of intercostal nerve blocks with standard and liposomal bupivacaine in thoracic surgical patients. While these studies add evidence to support the incorporation of these blocks into clinical practice, there is a need for large, well-controlled, and randomized clinical studies with meaningful patient outcomes before perioperative physicians can declare victory and adopt them into a new standard of care. The use of various non–opioid-based analgesics (ketamine, dexmedetomidine, lidocaine, acetaminophen, ketorolac, and gabapentin) in cardiac surgery is another topic of debate. Nazarnia et al reviewed and reported the evidence behind the use of non–opioid-based analgesics in cardiac surgery practice. While the cardiac anesthesia community has widely adopted the use of these medications as alternatives to opioids, the review pointed out the lack of clear evidence supporting the efficacy and safety of many of these non–opioid-based analgesics. Several questions remain unanswered. Do non–opioid-based analgesics provide equivalent or superior analgesia compared to opioids? Do they work synergistically when used in combination? Are non–opioid-based analgesics safe? Do they reduce opioid-related adverse events? Do they provide an outcome benefit? Does the use of opioid-sparing analgesics perioperatively decrease the amount of opioid use after discharge? Persistent pain after cardiac surgery has been described as a significant problem. Krakowski et al wrote an excellent review on the prevention and management of persistent pain for this issue and provided future directions for research. The authors supported the use of a non– opioid-based analgesic strategy and regional analgesia to decrease the amounts of opioids used but did not recommend opioid-free techniques, which may be harmful. There is also some evidence suggesting that the longer-acting opioid and NMDA receptor antagonist methadone may prevent the development of chronic persistent pain as well as