The Association Between Enhanced Recovery After Cardiac Surgery-Guided Analgesics and Postoperative Delirium

J Cardiothorac Vasc Anesth. 2023 May;37(5):707-714. doi: 10.1053/j.jvca.2022.12.023. Epub 2023 Jan 8.


Objectives: Delirium is a common postoperative complication associated with death and long-term cognitive impairment. The authors studied the association between opioid-sparing anesthetics, incorporating Enhanced Recovery After Cardiac Surgery (ERACS)-guided analgesics and postoperative delirium.

Design: The authors performed a retrospective review of nonemergent coronary, valve, or ascending aorta surgery patients.

Setting: A tertiary academic medical institution.

Participants: The study authors analyzed a dataset of elective adult cardiac surgical patients. All patients ≥18 years undergoing elective cardiac surgery from November 2, 2017 until February 2, 2021 were eligible for inclusion.

Interventions: The ERACS-guided multimodal pain regimen included preoperative oral acetaminophen and gabapentin, and intraoperative intravenous lidocaine, ketamine, and dexmedetomidine.

Measurements and main results: Delirium was measured by bedside nurses using the Confusion Assessment Method for the intensive care unit (ICU). Delirium occurred in 220 of the 1,675 patients (13.7%). The use of any component of the multimodal pain regimen was not associated with delirium (odds ratio [OR]: 0.85 [95% CI: 0.63-1.16]). Individually, acetaminophen was associated with reduced odds of delirium (OR: 0.60 [95% CI: 0.37-0.95]). Gabapentin (OR: 1.36 [95% CI: 0.97-2.21]), lidocaine (OR: 0.86 [95% CI: 0.53-1.37]), ketamine (OR: 1.15 [95% CI: 0.72-1.83]), and dexmedetomidine (OR: 0.79 [95% CI: 0.46-1.31]) were not individually associated with postoperative delirium. Individual ERACS elements were associated with secondary outcomes of hospital length of stay, ICU duration, postoperative opioid administration, and postoperative intubation duration.

Conclusions: The use of an opioid-sparing perioperative ERACS pain regimen was not associated with reduced postoperative delirium, opioid consumption, or additional poor outcomes. Individually, acetaminophen was associated with reduced delirium.

Keywords: Enhanced Recovery After Cardiac Surgery (ERACS); cardiac; delirium; multimodal analgesia; pain.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Acetaminophen
  • Adult
  • Analgesics
  • Analgesics, Opioid / adverse effects
  • Cardiac Surgical Procedures* / adverse effects
  • Dexmedetomidine*
  • Emergence Delirium* / diagnosis
  • Emergence Delirium* / epidemiology
  • Emergence Delirium* / prevention & control
  • Gabapentin
  • Humans
  • Ketamine*
  • Lidocaine
  • Pain, Postoperative / diagnosis
  • Pain, Postoperative / drug therapy
  • Pain, Postoperative / prevention & control


  • Acetaminophen
  • Analgesics, Opioid
  • Dexmedetomidine
  • Gabapentin
  • Ketamine
  • Analgesics
  • Lidocaine