Holistic Approach to Cardiac Surgery Can Sharply Cut Opioid Use

For patients who undergo cardiac surgery, systematic use of a two-pronged strategy that involves sternotomy closure with rigid-plate fixation (RPF) plus an enhanced-recovery protocol (ERP) can produce clinically meaningful decreases in opioid use, a single-center study suggests.

The findings were published online recently in the Annals of Thoracic Surgery.

Lead author Marc W. Gerdisch, MD (Franciscan Health Heart Center, Indianapolis, IN), told TCTMD that, in his view, the results they achieved represent a “breakthrough.”

Typically, most cardiac surgeons use wire cerclage for sternotomy closure, whereas RPF is more common in orthopedic surgery. For RPF, wiring is followed by fixation with titanium plates and bicortical screws, resulting in better healing and less pain. ERP, meanwhile, encompasses preoperative education, early ambulation, perioperative medication and analgesia planning, diet and bowel control, and other factors.

In combining RPF and ERP—an approach that mirrors the 2019 guidelines for Enhanced Recovery After Surgery (ERAS)—the team has taken measures to “avoid opioids and all their ill consequences [while] dramatically improving the overall experience for the patients, the time spent in the hospital, and their ability to return to their normal, full lifestyle quickly and avoid extended care facilities,” Gerdisch said.

Research has shown that many cardiac surgery patients given opioids to treat the pain of their procedures will continue to use the narcotics even months afterward, which can lead to addiction.

Prior to making these changes, Franciscan Health already had a robust minimally invasive program “where we had mastered the issues related to pain and mobility, and [patients] were leaving the hospital in 2 to 4 days,” Gerdisch pointed out. “We wanted to have the same thing for the sternotomy patients: why couldn't we achieve that? And that's what we pursued.”

Nimesh Desai, MD, PhD (Hospital of the University of Pennsylvania, Philadelphia), who’s studied trends in opioid use among cardiac surgery patients, agreed. “This really is, in a lot of ways, a trailblazing approach,” he commented to TCTMD.

The goal of reducing opioids in this setting is a worthy one, said Desai. “We use a lot of opioids  in cardiac surgery,” he noted, adding that without practices like early mobilization after surgery, patients can experience pain and tightness that continue for months. Thanks to growing awareness over the last decade that use of these medications can have long-term consequences, Desai said, physicians are now more judicious about administering them than in the past.

“What this study shows is if you take a completely different mindset towards [cardiac surgery, then] you can almost eliminate opioids out of the practice completely, certainly in the vast majority of patients,” Desai said. “And that's really remarkable.”

Less Opioids Didn’t Translate to More Pain

Gerdisch and colleagues reviewed data on 608 patients (mean age 65.7 years; 29.6% female) who underwent cardiac surgery with median sternotomy at their center over several eras:

• Controls whose sternal osteotomies were closed with wire cerclage and who were treated prior to implementation of either RPF or ERP (n = 224; July-December 2015)
• Patients whose surgery was done with RPF only (n = 218; March-August 2017)
• Those who received RPF plus ERP early in its adoption (n = 201; July-December 2020)
• Those who received RPF plus ERP after both strategies were well established (n = 174; January-June 2022)

Baseline characteristics and EuroSCORE were similar across the four cohorts, apart from a higher prevalence of congestive heart failure in the latter two eras. Most of the surgeries (59.2%) were isolated CABG, while 7.7% were isolated valve procedures and the rest were mixed/concomitant procedures.

In the hospital, postoperative opioid administration was a median of 172.5 morphine milligram equivalents (MME) in controls. By 2022, when RPF and ERP had both been in use for a few years, the median MME had dropped to zero—notably, patients reported similar or slightly reduced pain scores despite the lack of opioids.

Hospital length of stay and time to extubation did not change over time, though a higher proportion of patients were extubated in the operating room in later years.

Patients were increasingly discharged to home as opposed to an inpatient facility across the four time periods: rising from 66.2% of controls to 79.6% with RPF only, then again rising from 88.7% to 93.5% in the early and later RPF plus ERP eras (P < 0.0001 for trend).

At discharge, controls were prescribed a median of 600 MME, whereas in both RPF plus ERP eras, the median was again zero (P < 0.001). The majority of the RPF-only patients received an opioid prescription, whereas just 5% and 4.3% of patients in the two RPF plus ERP eras got one (P < 0.001).

There was a downward trend overall in 90-day readmission rates as well (P = 0.014). “It wasn't just the first 30 days where people were feeling and doing better. It was 3 months,” Gerdisch noted. “So that's a durable impact on the patient's entire recovery.”

It wasn't just the first 30 days where people were feeling and doing better. It was 3 months. Marc W. Gerdisch

The improvements have a real impact on patients, not only by reducing pain and thus the need for narcotics, but also by increasing independence, he stressed. “You can drive [and] you can lift 20 pounds in each arm when you leave the hospital. Perhaps more importantly for older, sicker, more debilitated folks: they can use their arms immediately to get out of bed, up and down from a chair, up and down from a toilet, use their walker . . . instead of being dependent on other people to mobilize them.”

The Path to Wider Adoption

Today, all of Franciscan Health’s cardiac surgery patients have the same order sets whether they undergo a minimally invasive procedure or sternotomy.

“The way that the patient moves through the system is exactly the same. So what that does is it opens things up for the entire team,” said Gerdisch. The consistency enables nurses to focus on issues like hemodynamics and volume status rather than “having to deal with treating pain, worrying about the sternal instability, [and] wondering if they can mobilize the patient. . . . You can't imagine how [much] that impacts the overall recovery for the patient as well as the morale of the program, because you've got people who are made whole quicker than they used to be.”

One thing that may be deterring wider adoption of sternotomy closure with RPF is the technique’s higher upfront cost, but within 6 months it pays for itself, he added. As for enhanced recovery, the need to coordinate many moving parts can be an obstacle.

The perceived barriers are why “we were thrilled to be able to get the paper out,” Gerdisch said. “I’ve presented some of this data in bits and pieces and talked to people about it. And I think that they were never really sure [about it]. Now we have concrete data that's been peer reviewed.”

In the years following the periods analyzed in this study, the protocols at Franciscan Health have evolved, said Gerdisch. They’ve begun extubating most cardiac surgery patients before they leave the operating room, for instance. Through this and other techniques, the team aims to “continue to condense the timeline and experience for the patient in the hospital,” he said.

For Desai, the ideal next step would be a larger randomized trial testing these strategies. Although there have been a few single-center reports and smaller studies, “what's missing really is the evidence base to say, ‘This technique is superior because of these reasons, and this is the quality of evidence that we have to show that.’ . . . I think this holistic approach of rigid fixation and the ERAS pathway in cardiac surgery is very intriguing and needs to be studied better within a clinical trial.”

All of these improvements, if they pan out, could shift the balance between open surgery and transcatheter interventions. The initial 90-day window “for a patient is a very scary period of time, especially when they consider that they could be in a lot of pain after the surgery,” he observed. “So if we can get to the point in cardiac surgery where you tell a patient that, ‘Yes, it's obviously a big invasive surgery, but you probably won't even need any pain medicine after the surgery,’ I think that that really will change people's perception of what their recovery is going to be like.”