Perioperative Pain Management in the Current Times: Drugs and Blocks Matter, but What Beyond?

Sir,

Perioperative pain management in cardiac surgery has long been a primarily opioid-based affair. Nonetheless, opioid stewardship is now being increasingly practiced across diverse cardiac surgical settings, with the aim of an enhanced recovery after surgery (ERAS), motivated by the growing evidence on the potential harms associated with high-dose opioids. The current objective is to optimize pain management by employing multimodal analgesia (non-opioid analgesics and regional techniques), curtailing the reliance on opioids, to minimize opioid-related adverse effects (ORADES) and persistent opioid use following cardiac surgery.[1]

A recently published joint consensus report of the PeriOperative Quality Initiative (POQI) and the ERAS cardiac society promulgated six recommendations on opioid stewardship in cardiac surgery. The recommendations emanated from structured literature appraisal and the modified Delphi method, involving an interdisciplinary panel of experts.[2] Meanwhile, the enthusiasm to research opioid-sparing regimes (varying combinations of non-opioid analgesics and regional techniques) continues to amplify, the set of additional interventions that could facilitate a judicious opioid use in cardiac surgery can simultaneously not be undermined. The latter is heralded by two of the six worthy recommendations of the POQI-ERAS group being dedicated to interventions focusing concepts beyond drugs and blocks.[2]

The first concept propounds the need for the requisite patient and provider education. The group recommends that “patients and healthcare providers receive formal education on perioperative analgesia for cardiac surgery, including pain management expectations, analgesic options, and potential side-effects” (recommendation grade: strong).[2] Indeed, cardiac surgical studies in this context are lacking, whereas the incorporation of patient–provider education has notably yielded encouraging results in the noncardiac surgical literature.[3] Moreover, larger benefits are expected to transpire from empowering the providers with a comprehensive knowledge of non-opioid analgesics and opioid stewardship principles, strengthening overall adherence to safe opioid prescribing. At the same time, a shared provider–patient decision-making is equally pivotal for successful opioid stewardship, reinforcing structured feedback pertaining the adequacy of pain relief.[2,3] In this regard, there exist areas of specific concern. For instance, recent studies in noble search of postoperative opioid-sparing owing to an opioid-free anesthesia fail to formally educate their participants on modulation of the intraoperative analgesic scheme.[4] The former only assumes an enhanced relevance when evidence does not conclusively suggest the efficacy-safety of practices such as routine intraoperative opioid elimination, aptly highlighted in an editorial by Kharasch and Clark.[5]

The POQI-ERAS group also recommends “the development of program-specific multidisciplinary pathways for perioperative pain management” (recommendation grade: strong). They further outline the value of adapting the pain management protocols to patient and procedure-specific considerations, to achieve realistic opioid reduction goals appropriate to the functioning system of perioperative care. The same requires to be additionally backed by an effective phase of care transition support, buttressing the role of system-level interventions.[2]

To conclude, the above recommendations surface at a particularly crucial time when the perioperative pain management in cardiac surgery is remodeling wherein formulating a “truly holistic” approach could not have been more important than ever before.

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Conflicts of interest

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