Goal-directed multimodal analgesia to enhance recovery after coronary artery bypass grafting: a retrospective cohort study

Inadequate pain control after coronary artery bypass grafting (CABG) impedes recovery. While Enhanced Recovery After Surgery (ERAS) protocols advocate opioid-sparing multimodal analgesia (MMA), standardized protocols may not address individual pain trajectories. This study evaluated whether an early, goal-directed multimodal analgesia (GDMA) strategy improves postoperative outcomes compared to conventional analgesia. This single-center retrospective cohort study included adults undergoing elective, isolated CABG (2019–2023). Patients were stratified into GDMA (analgesia titrated to predefined functional pain targets using ≥ 3 analgesic classes) or Traditional Analgesia (TA; opioid-centric, reactive) groups based on documented regimens. Primary outcomes were 48-hour opioid consumption (morphine milligram equivalents, MME) and pain scores (Numerical Rating Scale, NRS). Secondary outcomes included recovery milestones (mechanical ventilation duration, ICU/hospital length of stay) and complications. Propensity score matching (1:1) generated balanced cohorts (n = 210 per group). Multivariable regression adjusted for confounders. After matching, the GDMA group demonstrated significantly lower 48-hour opioid consumption (median MME: 48.5 vs. 75.0 mg; p < 0.001) and superior dynamic pain control during activity (significant group-by-time interaction, p = 0.003), despite comparable resting pain scores. The GDMA strategy was associated with accelerated recovery: shorter duration of mechanical ventilation (7.0 vs. 9.0 h, p < 0.001), time to first ambulation (22.5 vs. 32.0 h, p < 0.001), ICU stay (22.0 vs. 45.0 h, p < 0.001), and postoperative hospital stay (7.0 vs. 8.0 days, p < 0.001). Complication rates were significantly lower for GDMA regarding postoperative delirium (4.8% vs. 11.9%, p = 0.008), pulmonary infection (3.3% vs. 8.6%, p = 0.018), and nausea/vomiting (10.0% vs. 19.0%, p = 0.007). Multivariable analysis confirmed GDMA as an independent protective factor against prolonged hospital stay (aOR: 0.48) and delirium (aOR: 0.37). An early GDMA strategy after CABG significantly reduces opioid consumption, provides superior dynamic pain control, accelerates recovery, and decreases key complications. These findings suggest that an early GDMA strategy may represent a promising and safe paradigm within ERAS cardiac pathways.