Authors: Kleiman A M et al.
Anesthesia & Analgesia. 142(2):220–230, February 2026. 10.1213/ANE.0000000000007612
Summary
This large retrospective cohort study evaluated the association between multimodal analgesia use and enhanced recovery outcomes in adult patients undergoing elective cardiac surgery. Using data from the Society of Thoracic Surgeons database between 2020 and 2023, the authors examined outcomes in patients undergoing coronary artery bypass grafting, valve surgery, or combined procedures within enhanced recovery after cardiac surgery pathways. Multimodal analgesia was defined as the use of more than one pharmacologic analgesic targeting different receptor pathways.
Among more than 17,000 eligible cases, nearly 90% of patients received multimodal analgesia. After adjustment for clinical and procedural confounders, the use of multimodal analgesia was not associated with a reduction in the primary outcome of maximum postoperative pain score on postoperative day 3. However, multimodal analgesia was associated with shorter initial mechanical ventilation time. Patients who received multimodal analgesia were extubated earlier on average, and increasing numbers of analgesic agents were associated with progressively shorter ventilation times, suggesting a dose–response relationship for this outcome.
Analysis of individual analgesic components revealed heterogeneous effects. Acetaminophen use was associated with a lower likelihood of postoperative delirium, while the use of regional nerve blocks was associated with an increased likelihood of unplanned reintubation. No consistent associations were observed with reductions in pneumonia, ICU length of stay, or other secondary outcomes. The findings suggest that while multimodal analgesia may support earlier extubation in cardiac surgical patients, its effect on postoperative pain control is less clear and may depend on the specific agents used rather than the multimodal strategy alone.
What You Should Know
Multimodal analgesia was not associated with lower postoperative pain scores after elective cardiac surgery.
Use of multimodal analgesia was associated with shorter initial mechanical ventilation times, supporting faster extubation.
Increasing numbers of analgesic agents were associated with progressively shorter ventilation duration.
Individual agents may have divergent effects, with acetaminophen associated with reduced delirium and regional blocks associated with higher reintubation risk.
Key Points
Question: Does multimodal analgesia improve enhanced recovery outcomes after elective cardiac surgery?
Findings: Multimodal analgesia was associated with earlier extubation but not with improved postoperative pain scores.
Meaning: Multimodal analgesia may facilitate faster ventilator liberation, but optimization of specific drug combinations is needed to maximize benefit and minimize risk.
Thank you to Anesthesia & Analgesia for publishing this important evaluation of ERACS analgesic strategies.