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NSAID-analgesia, pain control and morbidity in cardiothoracic surgery

[L’analgésie avec des AINS, le contrôle de la douleur et la morbidité en chirurgie cardiothoracique]

Daniel Bainbridge, MD FRCPC^*, Davy C. Cheng, MD MSc FRCPC^*, Janet E. Martin, Pharmd, Richard Novick, MD MSC FRCSC and The Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR) Group

^* From the Department of Anesthesia and Perioperative Medicine,
Department of Pharmacy, Physiology and Pharmacology, and
the Division of Cardiac Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.

Address correspondence to: Dr. D. Cheng, Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre - University Hospital, Main Building, Room C3-172, 339 Windermere Road, London, Ontario N6A 5A5, Canada. Phone: 519-663-3031; Fax: 519-663-3161; E-mail: davy.cheng{at}lhsc.on.ca

Objective: While narcotics remain the backbone of perioperative analgesia, the adjunctive role of other analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), is being recognized increasingly. This meta-analysis sought to determine whether adjunctive NSAIDs improve postoperative analgesia and reduce cumulative narcotic requirements.

Methods: A comprehensive search was undertaken to identify all randomized trials, in cardiothoracic patients, of NSAIDs plus narcotics vs narcotics without NSAIDs. Medline, Cochrane Library, EMBASE, and abstract databases were searched up to September 2005. The primary outcome was visual analogue scale (VAS) pain score. Secondary outcomes included 24-hr cumulative morphine-equivalents, rescue medications required, mortality, myocardial infarction, atrial fibrillation, stroke, renal failure, hospital readmissions, and in-hospital costs.

Results: Twenty randomized trials involving 1,065 patients were included. A significant reduction in 24-hr VAS pain score was found in patients receiving NSAIDs [weighted mean difference (WMD) –0.91 points, 95% confidence interval (CI) –1.48 to –0.34 points]. In addition, patients required significantly less morphine-equivalents in the first 24 hr (WMD –7.67 mg, 95% CI –8.97 to –6.38 mg). No significant difference was found with respect to mortality [odds ratio (OR) 0.19, 95% CI 0.01 to 4.22], myocardial infarction (OR 0.71, 95% CI 0.09 to 5.71), renal dysfunction (OR 0.95, 95% CI 0.37 to 2.46), or gastrointestinal bleeding (OR 0.96, 95% CI 0.13 to 7.09).

Conclusion: In patients less than 70 yr of age undergoing cardiothoracic surgery, the adjunctive use of NSAIDs with narcotic analgesia reduces 24-hr VAS pain score and narcotic requirements.

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