The impact of multimodal analgesia in coronary artery bypass graft surgery—a population-based analysis

Objective Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS) and opioid consumption among patients undergoing coronary artery bypass graft (CABG) surgery. Methods This retrospective cohort study included 349,940 adult patients undergoing elective CABG surgery (01/2006-12/2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of non-opioid analgesic modalities. These included, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids-only and multimodal analgesia with the addition of 1, 2 or ≥3 non-opioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in Milligram Oral Morphine Equivalents (OME). Results Multimodal analgesia was associated with a beneficial dose response pattern. With increasing non-opioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed: e.g. with the addition of 1, 2, or ≥3 non-opioid modalities the odds for any complication decreased by 8% (OR 0.92 (CI 0.90;0.94), 17% (OR 0.83 (CI 0.81;0.86) and 22% (OR 0.78 (CI 0.69;0.79), respectively. This pattern was consistent in respiratory, cardiac and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities. Conclusion This nationally representative data indicates that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.