Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis

Kiyan Heybati; Fangwen Zhou; Matthew Joseph Lynn; Jiawen Deng; Saif Ali; Wenteng Hou; Shayan Heybati; Kosta Tzanis; Magnus Krever; Rafay Mughal; Harish Ramakrishna

doi:10.1053/j.jvca.2023.03.018

Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis

J Cardiothorac Vasc Anesth. 2023 Jul;37(7):1169-1178. doi: 10.1053/j.jvca.2023.03.018. Epub 2023 Mar 18.

Authors

Kiyan Heybati¹, Fangwen Zhou², Matthew Joseph Lynn³, Jiawen Deng⁴, Saif Ali⁵, Wenteng Hou⁶, Shayan Heybati⁷, Kosta Tzanis⁸, Magnus Krever⁹, Rafay Mughal⁶, Harish Ramakrishna¹⁰

Affiliations

¹ Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN.
² Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
³ Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
⁴ Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁵ Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
⁶ Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
⁷ Faculty of Science, Queen's University, Kingston, ON, Canada.
⁸ Faculty of Science, University of Toronto, Toronto, ON, Canada.
⁹ Faculty of Science, Wilfrid Laurier University, Waterloo, ON, Canada.
¹⁰ Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN. Electronic address: Ramakrishna.harish@mayo.edu.

PMID: 37088644
DOI: 10.1053/j.jvca.2023.03.018

Abstract

Objectives: To compare the relative efficacy of adjuvant nonopioid analgesic regimens in adult cardiac surgical patients.

Design: This frequentist, random-effects network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021282913) and conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA). The risk of bias (RoB) and confidence of evidence were assessed by RoB 2 and Confidence in Network Meta-Analysis, respectively. Relevant databases were searched from inception to October 9, 2021.

Setting: A total of 124 (N = 26,257) randomized controlled trials were included, of which 110 were analyzed.

Participants: Trials enrolling adults (≥18 years of age) undergoing cardiac surgery that compared nonopioid analgesics against other nonopioid analgesics, placebo, or no additional treatment, as adjuvants to standard analgesic management, and reported at least 1 of the outcomes of interest.

Measurement and main results: Outcomes of interest included resting postoperative pain scores at 24 hours. Compared with standard care and/or placebo, pain scores were reduced significantly by 10 different regimens, including acetaminophen (N = 176; mean difference [MD] -0.66 points, 95% CI -1.16 to -0.15 points; high confidence), magnesium (N = 323; -0.05 points, 95% CI -0.07 to -0.02 points; high confidence), gabapentin (N = 96; MD -0.40 points, 95% CI -0.71 to -0.09; moderate confidence), and clonidine (N = 64; MD v0.38 points, 95% CI -0.73 to v0.04 points; moderate confidence). Indomethacin, diclofenac, magnesium, and gabapentin significantly reduced 24-hour opioid consumption. Four regimens significantly decreased the intensive care unit length of stay. Hydrocortisone, dexmedetomidine, and clonidine significantly decreased the duration of mechanical ventilation. Magnesium decreased, while methylprednisolone significantly increased, the risk of myocardial infarction.

Conclusions: Given the increasing emphasis on enhanced recovery after surgery(ERAS) protocols and the eventual goal of limiting opiate prescriptions postoperatively, the authors' data suggested far greater use of nonopioid adjuncts to minimize pain and enhance recovery following cardiac surgery.

Keywords: cardiac surgery; network meta-analysis; non-opioid analgesia; pain management; postoperative outcomes.

Publication types

Meta-Analysis

MeSH terms

Adult
Analgesia* / methods
Analgesics / therapeutic use
Analgesics, Non-Narcotic* / therapeutic use
Cardiac Surgical Procedures* / adverse effects
Clonidine / therapeutic use
Gabapentin / therapeutic use
Humans
Magnesium
Network Meta-Analysis
Pain, Postoperative / diagnosis
Pain, Postoperative / drug therapy
Pain, Postoperative / prevention & control

Substances

Analgesics, Non-Narcotic
Gabapentin
Clonidine
Magnesium
Analgesics