Abstract

Background: Cardiac anesthesia has traditionally relied on large opioid doses to maintain hemodynamic stability and suppress sympathetic stimulation. Emerging evidence supports opioid-sparing strategies using dexmedetomidine, ketamine, lidocaine, and magnesium, which are associated with reduced postoperative nausea and vomiting (PONV), faster extubation, shorter intensive care unit (ICU) stays, and decreased inotrope requirements. In the context of the opioid crisis, anesthesia providers are encouraged to reassess opioid-heavy techniques and adopt Enhanced Recovery After Cardiac Surgery (ERACS) protocols emphasizing multimodal care. A 67-year-old male with hypertension and hyperlipidemia underwent elective three-vessel coronary artery bypass grafting (CABG) with normal ejection fraction (55–60%). Anesthesia was induced with fentanyl, lidocaine, propofol, and succinylcholine and maintained with isoflurane. Hemodynamics were stable except for transient hypertension during vein harvesting and sternotomy, treated with incremental fentanyl boluses totaling 2000 mcg. Cardiopulmonary bypass weaning was uncomplicated with brief low-dose epinephrine and phenylephrine. Despite clinical stability, reliance on high-dose opioids without multimodal adjuncts highlighted practice variability.

Clinical Question: In adult patients undergoing cardiac surgery (CABG or valvular repair), how does opioid-sparing or opioid-free anesthesia, compared with traditional high-dose opioid anesthesia, affect postoperative opioid consumption (primary outcome) and PONV, inotrope use, time to extubation, and ICU length of stay (secondary outcomes)?

Evidence-Based Discussion: Evidence demonstrates that multimodal regimens using dexmedetomidine, ketamine, lidocaine, magnesium sulfate, and acetaminophen maintain hemodynamic stability while reducing postoperative opioid use, PONV, ventilation duration, ICU stay, and inotrope requirements, without increasing atrial fibrillation, acute kidney injury, delirium, or mortality. ERACS protocols reinforce opioid stewardship and standardized multimodal care, whereas traditional high-dose opioid techniques may delay recovery and increase sedation.

Translation to Practice: Implementing ERACS-guided opioid-sparing protocols for elective CABG and valvular surgery could improve postoperative outcomes. A pilot protocol could include preoperative education, acetaminophen with or without gabapentinoids, intraoperative multimodal infusions, and opioids reserved for rescue dosing.

Author Details

Sasha Ballard, DNP(c), BSN

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Case Study/Series

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Opioid-Sparing Anesthesia, Opioid-Free Anesthesia, Coronary Artery Bypass Graft, Valvular Repair, Enhanced Recovery, Adult Patients

Advisor

Lauren Barnes

Second Advisor

Lisa Herbinger

Degree

DNP

Degree Grantor

Samford University

Degree Year

2026

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Proxy-submission

Date of Issue

2026-01-28

Full Text of Presentation

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Abstract.pdf (155 kB)

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