Rigid Sternal Fixation and Enhanced Recovery for Opioid-free Analgesia After Cardiac Surgery.

ABSTRACT

BACKGROUND: We evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice. METHODS: This single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent surgery before implementation of RPF or ERP ("Controls"), patients closed with RPF prior to ERP implementation ("RPF-only") and patients managed with RPF and ERP during early "RPF+ERP-2020" and late "RPF+ERP-2022" implementation. RESULTS: Six hundred and eight median sternotomy patients (mean age 65.7 ± 10.8 y; 29.6% female) were included in the analysis. Of those, 59.2% were isolated coronary artery bypass grafting and 7.7% were isolated valve procedures; the remainder were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents in the control cohort versus 0 morphine milligram equivalents for RPF+ERP-2022 (P<.0001) despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls versus 79.6% for RPF-only (P=.010) and 93.5% for RPF+ERP-2022 (P<.0001). Median opioids prescribed at discharge were 600 morphine milligram equivalents for controls versus 0 for RPF+ERP-2020 and RPF+ERP-2022 (P<.0001); 86.7% of RPF-only patients received prescription opioids at discharge versus 5% and 4.3% in RPF+ERP-2020 and RPF+ERP-2022, respectively (P<.0001). These outcomes occurred without increased readmissions. CONCLUSIONS: Systematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population.