ARTICLE DOI: 10.31480/2330-4871/207

Review Article | Volume 12 | Issue 1 Open Access

Optimizing Perioperative Analgesia in Cardiac Surgery: An Updated Mini-Review of Multimodal Strategies

Daniel H Xue, BS1*, Andrew F Ibrahim, BS1 and Frank R Chen, MD2

1Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA

2Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA

*Corresponding author: Daniel H Xue, BS, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA

Editor: Renyu Liu, MD; PhD; Professor, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Center of Penn Global Health Scholar, 336 John Morgan building, 3620 Hamilton Walk, Philadelphia, PA 19104, USA, Fax: 2153495078, E-mail: RenYu.Liu@pennmedicine.upenn.edu

Received: Oct 04, 2025 | Accepted: Nov 03, 2025 | Published: Nov 07, 2025

Citation: Daniel H Xue, Andrew F Ibrahim, BS, Frank R Chen. Optimizing Perioperative Analgesia in Cardiac Surgery: An Updated Mini-Review of Multimodal Strategies. Transl Perioper Pain Med 2025; 12(2):773-776

Abstract

The opioid epidemic necessitates a paradigm shift in postoperative pain management for cardiac surgery. Multimodal analgesia (MMA) within Enhanced Recovery After Surgery (ERAS) protocols reduces opioid consumption while improving patient outcomes. MMA integrates non-opioid analgesics, regional anesthesia techniques like fascial plane blocks, and systemic adjuncts to target multiple pain pathways. Recent evidence shows significant reductions in opioid use, shorter hospital stays, and decreased complications such as ileus and delirium. However, gaps persist in protocol standardization, efficacy in high-risk populations (e.g., those with endocarditis or liver disease, potentially due to altered drug metabolism), and long-term impacts on chronic pain and renal function. This mini-review consolidates recent (2022-2025) data, highlighting new evidence on fascial plane blocks and implementation challenges, and proposes directions for future research to optimize analgesia in cardiac surgery.

Background

Postoperative pain following cardiac surgery arises from sternotomy, thoracotomy, and extensive tissue manipulation. For decades, opioids have primarily addressed this pain. While effective in blunting acute discomfort, opioids lead to troubling side effects, including respiratory depression, ileus, nausea, and delayed recovery [1]. The ongoing opioid crisis heightens these risks, as excessive reliance on opioids contributes to dependency and broader societal burdens [2]. In response, MMA reduces opioid consumption while improving patient outcomes. MMA blends low-dose opioids with non-opioid medications such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids, alongside regional techniques, to curtail opioid needs while bolstering overall pain relief [3]. This approach aligns with ERAS protocols tailored for cardiac procedures, which prioritize early mobilization, shorter intensive care unit (ICU) stays, and superior patient outcomes [4]. Where once opioid-heavy regimens prolonged intubation and hospital admissions, MMA now steers toward opioid-sparing methods that mitigate the epidemic’s impact [5].

MMA Mechanisms

MMA addresses pain through multiple pathways- nociceptive, inflammatory, and neuropathic- permitting substantial opioid dose reductions and fewer adverse effects [6]. In cardiac surgery, MMA’s advantages extend beyond pain control to encompass fewer opioid-linked complications, refined analgesia, and accelerated recovery [7]. Regional anesthesia plays a pivotal role, with fascial plane blocks offering a safer alternative to traditional neuraxial methods. Blocks such as parasternal, pectoralis (PECS), or serratus anterior plane (SAP) deliver precise analgesia without hemodynamic disruptions that complicate recovery, thus supporting broader opioid-sparing goals [8].

Evidence

Recent investigations illuminate MMA's potential to reduce opioid use in ERAS settings. To provide a clear overview of this supporting data, Table 1 synthesizes findings from key studies, including their sample sizes, interventions, opioid reductions, and primary outcomes. This compilation highlights the consistency of MMA's benefits across systemic, regional, and combined approaches, demonstrating its role in minimizing opioid reliance while maintaining effective pain control and enhancing recovery metrics.

Table 1: Summary of key studies on multimodal analgesia in cardiac surgery.

Study (Year) Sample Size Intervention Δ total MME Primary Outcomes
Graham, et al. [9] 23,238 NSAIDs + dexamethasone -29.5 MME ↓ Pain (1.0 NRS), shorter recovery
Darras, et al. [10] 2,052 Parasternal block in ERAS -20 MME ↓ Ventilation, ileus, delirium; shorter ICU
Loria, et al. [11] 466 Gabapentin + acetaminophen/NSAIDs -193 MME ↓ Perioperative opioid use
Rafiq, et al. [12] 151 Dexamethasone + gabapentin + ibuprofen Marked ↓ in total MME ↑ Pain control, ↓ nausea; no renal injury
Rauseo, et al. [13] 58,998 MMA + regional blocks -2.48 MME ↓ ICU stay, pain; no mortality Δ
Wynne, et al. [14] Review Multimodal analgesics Marked ↓ in total MME ↑ Pain control

(Δ total MME = change in total perioperative morphine milligram equivalents)

Systemic Interventions

Pairings like NSAIDs with dexamethasone achieve reductions of up to 29.5 MME, underscoring their edge over acetaminophen alone [9]. A randomized trial pitting MMA- using dexamethasone, gabapentin, ibuprofen, and paracetamol- against a morphine-paracetamol regimen showed superior pain scores and far less nausea/vomiting in the MMA arm, with no compromise to renal safety [12]. Narrative reviews detail how systemic adjuncts enhance cardiothoracic care by curbing opioids and syncing with ERAS to boost recovery and satisfaction [8].

Regional Anesthesia

Parasternal plane blocks (PPB) in an ERAS program achieve a 94% opioid-free rate in the ICU, compared to just 19.9% in controls, with median ICU opioid use falling from 31 to 11 MME [10]. Techniques like PECS and SAP blocks facilitate rapid extubation and diminished opioid demands [15]. Ultrasound guidance propels a move toward opioid-free anesthesia, trimming complications and aligning with ERAS principles [16].

Combination Approaches

An ERAS rollout featuring gabapentin, lidocaine, and acetaminophen/NSAIDs produces a 57% drop in total opioid use (from 452 to 259 MME), though patients with a history of intravenous drug use see no such benefit, hinting at tolerance as a limiting factor [11]. A 2025 meta-analysis of opioid-sparing approaches in cardiac procedures confirms reduced opioid intake without sacrificing pain management [13]. A systematic review from 2025 assesses multimodal analgesics’ impact on post-cardiac surgery pain in adults, finding marked enhancements in pain control and opioid sparing [14].

Challenges

Even with these advances, notable gaps linger in the literature. Protocols lack standardization, as they differ widely in their choice of agents and fascial plane blocks, complicating broader application [9,10]. MMA shows limited efficacy in high-risk groups, such as intravenous drug users, where tolerance undermines its effectiveness [11]. Insufficient data exist on endocarditis patients, where opioid-sparing benefits vary considerably; hypotheses suggest that infection-related inflammation alters pain pathways or increases opioid tolerance due to prior intravenous drug use in many cases, potentially reducing MMA benefits; preliminary data from ERAS studies often exclude these patients due to infection risks, guiding future research toward tailored regimens that account for antimicrobial interactions [9,11]. Similarly, scant evidence addresses liver disease patients, where altered drug metabolism (e.g., impaired clearance of acetaminophen or opioids) hypothesizes reduced MMA efficacy or heightened hepatotoxicity risks; preliminary reviews recommend multimodal strategies with regional techniques to minimize systemic drug loads, but dedicated trials are needed to test liver-safe combinations [9,11]. On the safety side, NSAIDs cause minor, non-significant creatinine elevations, but extended data on renal health in patients with cardiac comorbidities remain lacking [9,12]. Chronic pain, which affects 20–50% of patients after surgery [15], receives scant attention, with most research focused on acute phases rather than MMA’s potential to prevent long-term issues [8]. Barriers to rollout, such as the resources required for fascial plane blocks, are seldom explored [16], while analyses parsing minimally invasive versus open surgeries lack consistency [10,15]. Finally, evaluations of cost-effectiveness and adaptability across varied healthcare environments are overdue; a 2023 registry-based study showed that a perioperative pain management bundle reduced hospital costs by €1,138 per patient through shorter stays and fewer complications, suggesting similar savings may apply in cardiac surgery with further study [18].

Future Directions

Research should prioritize multicenter randomized trials to standardize MMA protocols, embedding fascial plane blocks within ERAS while tracking long-term outcomes like chronic pain [4]. Trials centered on high-risk subgroups- particularly endocarditis and liver disease patients- will refine personalized tactics [11]. A preliminary MMA framework includes core drugs (acetaminophen, NSAIDs, gabapentin) and fascial plane blocks (parasternal for sternotomy, PECS for broader coverage), adjusted for comorbidities and surgical type [9-10]. Emerging adjuncts like liposomal bupivacaine and pharmacogenomics-based dosing hold promise [19]. Training in ultrasound-guided blocks and shared registries will accelerate uptake and close evidence gaps [16,20].

Conclusion

Multimodal analgesia transforms postoperative care in cardiac surgery, aligning with ERAS principles to reduce opioid reliance while preserving pain control and recovery quality. Despite robust evidence of benefit, heterogeneity in protocols, underrepresentation of high-risk populations and limited long-term outcomes research remain barriers to full adoption. Standardized frameworks integrating fascial plane blocks, validated through multicenter trials and real-world registries, will define the next-generation ERAS standard and improve outcomes across diverse healthcare systems. This mini-review consolidates recent (2022-2025) evidence, emphasizing novel insights into fascial plane blocks and addressing implementation barriers.

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