2025 Southeastern Residency Conference

TITLE: Comparison of Analgesia Following Coronary Artery Bypass Grafting with the Use of Scheduled Acetaminophen
 
AUTHORS: Morgan Carhart, Brock Dorsett, Emily Johnson, Kayla Pangburn
BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are comprehensive, patient-centered, and evidence-based protocols that improve post-operative patient outcomes. Pain management is a major focus of ERAS protocols, which advocate for a multimodal, opioid-sparing approach to reduce hospital length of stay (LOS), complications, and opioid use following surgery. Intravenous (IV) acetaminophen (Ofirmev) is often used as a part of ERAS protocols and its use in the post-operative setting has been established for many different procedures. However, there are relatively few studies examining its use post-cardiac surgery and its benefits in terms of reducing post-operative opioid consumption are unclear. In January 2024, Cape Fear Valley Medical Center implemented an ERAS protocol for patients undergoing coronary artery bypass grafting (CABG) that includes one dose of IV acetaminophen followed by scheduled oral acetaminophen and as-needed hydromorphone via patient-controlled analgesia (PCA) pump. The purpose of this study was to evaluate the effects of initiating scheduled acetaminophen following CABG on the utilization of opioids during the first 48-hour post-operative period.
METHODS: This was a retrospective, single-center cohort study that included patients receiving CABG at Cape Fear Valley Medical Center from January 2023 to December 2024. The pre-ERAS group included patients receiving CABG from January to December 2023, and the post-ERAS group included patients receiving CABG from January to December 2024 that received the scheduled acetaminophen protocol. The primary endpoint was the difference in mean oral morphine milligram equivalents (oMMEs) used by patients receiving CABG before and after the implementation of the ERAS protocol at Cape Fear Valley Medical Center.
RESULTS: 301 patients met inclusion criteria with 143 in the pre-ERAS group and 157 in the post-ERAS group. Patients in the pre-ERAS group used a mean of 179.25 oMMEs compared to 193 oMMEs in the post-ERAS group (difference 13.75, 95% CI -42.22 to 14.72, p=0.34). There were no significant differences in secondary endpoints including as-needed opioid use, length of stay, or naloxone use between groups, but patients in the pre-ERAS group used more non-opioid pain medications than patients in the post-ERAS group (40 vs. 26, p=0.017).
CONCLUSION: The use of scheduled acetaminophen post-CABG did not significantly reduce the amount of total oMMEs for patients undergoing CABG within the 48-hour post-operative period. Limitations to the study that should be considered include the retrospective nature of this study, utilization of acetaminophen post-CABG in the pre-ERAS group, and a higher number of opioid-tolerant patients on admission in the post-ERAS group.