Authors: Faloye AO et al.
Source: Anesthesia & Analgesia, 142(2):215–218, February 2026.
Summary
This editorial evaluates the role of multimodal analgesia within Enhanced Recovery After Cardiac Surgery (ERACS) pathways in light of a large multicenter retrospective analysis by Kleiman et al using Society of Thoracic Surgeons data. While Enhanced Recovery After Surgery (ERAS) protocols have shown clear benefits across many surgical specialties, their application in cardiac surgery remains relatively new, and optimal analgesic strategies are still being defined.
The authors discuss the unexpected finding that multimodal analgesia was not associated with lower maximum pain scores on postoperative day (POD) 3. They argue that this result likely reflects methodological limitations rather than true inefficacy. Key concerns include restrictive timing criteria that excluded pre-incisional and pre-induction analgesics, misclassification of patients receiving early regional blocks, and reliance on a single pain score measured only on POD 3—an approach that inadequately represents postoperative pain trajectories.
The editorial highlights that effective multimodal analgesia depends not just on medication choice, but on timing, sequencing, and integration into a broader ERACS framework. Preemptive analgesia, particularly regional techniques and NMDA receptor antagonists, may reduce central sensitization and improve downstream recovery, but these effects were not captured in the analyzed dataset.
Secondary outcomes provided more encouraging signals. Acetaminophen use was associated with modest but clinically meaningful reductions in mechanical ventilation duration, ICU length of stay, and delirium. In contrast, dexmedetomidine was associated with longer ventilation times, likely reflecting its sedative role in ICU management rather than a direct adverse analgesic effect. An observed association between regional nerve blocks and unplanned reintubation is discussed cautiously, with the authors emphasizing that retrospective data cannot establish causality and may reflect premature extubation or variability in block efficacy.
Importantly, the authors argue that pain scores alone are a poor surrogate for patient-centered recovery. Persistent postoperative pain after cardiac surgery remains common, and poorly controlled acute pain—not numeric pain scores per se—is a predictor of chronic pain, long-term opioid use, impaired function, and reduced quality of life. They suggest that future ERACS research should focus on functional recovery, satisfaction, opioid exposure, and return to baseline activity rather than isolated pain metrics.
Overall, the editorial frames this study as a call to action: national databases need anesthesia-specific variables and more granular pain and analgesic data, and prospective studies are required to define optimal multimodal analgesic combinations and timing in cardiac surgery. Despite limitations, the findings support continued incorporation of acetaminophen as a foundational element of ERACS protocols.
Key Points
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Absence of lower POD 3 pain scores likely reflects timing and data limitations, not failure of multimodal analgesia
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Pre-incisional and early analgesia are core ERACS elements that were not captured
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Single-point pain assessment inadequately reflects postoperative pain experience
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Acetaminophen was associated with shorter ventilation time, reduced ICU stay, and less delirium
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Patient-centered outcomes are more meaningful than pain scores alone
What You Should Know
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ERACS effectiveness should be judged by recovery quality, function, and opioid exposure
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Timing of analgesic interventions is as important as medication selection
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National cardiac surgery databases currently lack key anesthesia and pain variables
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Acetaminophen has the strongest and most consistent benefit signal in cardiac ERACS protocols
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Future ERACS research should prioritize functional recovery and long-term outcomes
Thank you for allowing us to highlight and summarize this important editorial from Anesthesia & Analgesia, which continues to shape patient-centered perioperative care in cardiac anesthesia.