Nonsteroidal Antiinflammatory Drugs Used in Cardiac Surgery: A Survey of Practices and New Insights for Future Studies

We would like to share the results from our survey on nonsteroidal antiinflammatory drug (NSAID) use during cardiac surgery. Acute postoperative pain management remains a primary concern after cardiac surgery, as it may impair full recovery, delay rehabilitation, and lead to chronic pain.1Lahtinen P Kokki H Hynynen M. Pain after cardiac surgery: A prospective cohort study of 1-year incidence and intensity.Anesthesiology. 2006; 105: 794-800Crossref PubMed Scopus (220) Google Scholar Multimodal pain management based on the association of several drugs, including paracetamol, nefopam, and others, allows a reduction in pain and opioid consumption (and the related side effects). Nonsteroidal antiinflammatory drugs are part of these multimodal strategies, and are used widely for the reduction of pain and opioid consumption in noncardiac surgery, and thus also may play a role during cardiac surgery.2Moote C. Efficacy of nonsteroidal anti-inflammatory drugs in the management of postoperative pain.Drugs. 1992; 44: 14-30Crossref PubMed Scopus (141) Google Scholar To date, few studies have assessed their use in this setting. Nevertheless, the experts from the Enhanced Recovery After Surgery Society guidelines did not recommend their use regarding the potential for kidney dysfunction.3Engelman DT Ben Ali W Williams JB et al.Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations.JAMA Surg. 2019; 154: 755-766Crossref PubMed Scopus (535) Google Scholar This position was based on a single-center, randomized study using high doses of ibuprofen, with a slight and transient increase in acute kidney injury (AKI).4Qazi SM Sindby EJ Nørgaard MA. Ibuprofen—A safe analgesic during cardiac surgery recovery? A randomized controlled trial.J Cardiovasc Thorac Res. 2015; 7: 141-148Crossref PubMed Google Scholar Other studies did not show such effects.5Hynninen MS Cheng DC Hossain I et al.Non-steroidal anti-inflammatory drugs in treatment of postoperative pain after cardiac surgery.Can J Anaesth. 2000; 47: 1182-1187Crossref PubMed Scopus (93) Google Scholar,6Bainbridge D Cheng DC Martin JE et al.NSAID—analgesia, pain control and morbidity in cardiothoracic surgery.Can J Anaesth. 2006; 53: 46-59Crossref PubMed Google Scholar In light of these conflicting data and guidelines, we wanted to describe the habits of French anesthesiologists regarding their use of NSAIDs in cardiac surgery, allowing us to drive future clinical trials on this topic. We conducted a prospective declarative survey during a 2-month period in 2021. The survey was sent electronically to the members of ARCOTHOVA (Thoracic and Vascular Surgery Anesthesiologist Society) via the online software SurveyMonkey. The survey was anonymous, and responders were able to skip some questions at their discretion. The complete survey is available in the Supplementary Material. It was divided into 3 parts: (1) general questions about respondents, (2) questions about the use (or not) of NSAIDs in cardiac surgery, (3) details of the practice concerning NSAIDs in cardiac surgery (eg, indications, dose, contraindications). Data are presented as absolute numbers or percentages and medians with interquartile ranges, as appropriate. The survey was sent to 560 caregivers, and 74 answered the survey (response rate: 13.2%): 68 senior physicians and 6 junior physicians with a median experience of 7 (3-12) years in the specialty (Table 1). Only 10% (n = 7) declared they never used NSAIDs, 85% (n = 63) frequently, and 5% (n = 4) always (Fig 1). Among the 7 physicians who did not use NSAIDs, the main reasons to avoid NSAIDs were the risks of kidney injury (4 of 7), bleeding (3 of 7), and gastric injury (2 of 7).Table 1Respondents’ Demographic CharacteristicsVariablesRespondents N = 74Age, y39 (35-48)Male sex, n (%)43 (58)Professional status, n (%) Attending physician, public53 (72) Assistant Professor6 (8) Professor5 (7) Physicians (private exercise)10 (13)Specialty, n (%) Anesthesiologist72 (98) Others2 (2)Activity location, n (%) Public hospital2 (3) University hospital62 (84) Private clinic9 (12) Other1 (1) Experience, y6.5 (3.0-12.0)Type of ward, n (%) ICU exclusively6 (8) OR exclusively7 (9) Both61 (83)Abbreviations: ICU, intensive care unit; OR, operating room. Open table in a new tab Abbreviations: ICU, intensive care unit; OR, operating room. Among respondents, 81% (n = 57) declared using NSAIDs for coronary artery bypass graft (with cardiopulmonary bypass), 87% (n = 61) for valvular surgery, 67% (n = 47) for combined surgery, 40% (n = 28) for redo surgery, 44% (n = 31) for aortic root surgery, and only 9% (n = 6) for transcatheter aortic valve replacement. In most cases (84%, n = 64), NSAIDs were not considered for procedures with deep hypothermia (<30°C). Respondents suggested ketoprofen (99%) and sometimes ibuprofen (6%) administration. Diclofenac and naproxen were suggested by only 1% of respondents. Doses of ketoprofen ranged from 50 mg every 8 hours to 100 mg every 8 hours. The use of NSAIDs was part of a multimodal analgesia approach, including regular use of nefopam (97%), morphine (90%), and tramadol (74%). Physicians declared the regular use of ketamine (91%) and dexamethasone (61%) in the operating room. Concerning contraindications, only 51% of physicians did not consider NSAIDs in people older than 75 (70-80). Only 10% avoided NSAIDs in patients under single antiplatelet therapy (aspirin or clopidogrel), but 57% considered the association of dual or more antiplatelet therapy as a contraindication, and 30% did not consider NSAIDs for patients under curative anticoagulant therapy. In patients with a history of arterial thrombosis (cerebral or cardiac stroke, peripheral ischemia, or other), only 14% avoided NSAIDs. The most striking finding in our survey was the use of NSAIDs among 90% of respondents despite current guidelines not recommending them.3Engelman DT Ben Ali W Williams JB et al.Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations.JAMA Surg. 2019; 154: 755-766Crossref PubMed Scopus (535) Google Scholar The absence of strong evidence for a harmful effect of NSAIDs may explain this discrepancy. Nevertheless, the absence of evidence does not mean the absence of effect, and some points must be discussed. First, NSAIDs may enhance renal failure because of their vasoconstrictive effects on renal vascularization. The risk of AKI may greatly differ according to patient and surgical risk factors. Thus, a rational approach may be the use of NSAIDs in patients at low risk of AKI, in association with close monitoring of postoperative renal function and fluid administration. Second, bleeding or gastrointestinal injuries were reported to be a concern for respondents. Cardiac surgery is a high risk for bleeding, and because NSAIDs may disturb platelet function, their use may be questionable in high-risk situations. Nevertheless, no current evidence for a higher incidence of bleeding and/or transfusion has been documented in cardiac surgery despite studies not being designed for this purpose; therefore, we cannot conclude definitively.4Qazi SM Sindby EJ Nørgaard MA. Ibuprofen—A safe analgesic during cardiac surgery recovery? A randomized controlled trial.J Cardiovasc Thorac Res. 2015; 7: 141-148Crossref PubMed Google Scholar,7Kulik A Ruel M Bourke M et al.Postoperative naproxen after coronary artery bypass surgery: A double-blind randomized controlled trial.Eur J Cardio-Thorac Surg. 2004; 26: 694-700Crossref PubMed Scopus (41) Google Scholar Although no significant increase in gastrointestinal damage was observed in these studies, the risks and benefits of NSAIDs should be weighed in patients and/or situations at high risk of gastrointestinal or systemic bleeding. Indeed, >50% of respondents avoided NSAIDs in redo, aortic root, or deep hypothermia surgeries. In the same way, 57% of respondents did not consider NSAIDs in cases of double-antiplatelet therapy, which was consistent with the excess risk of bleeding identified in the literature. Third, NSAIDs have been described as increasing the risk of myocardial infarction, notably at high doses and long-lasting exposure.8Bally M Dendukuri N Rich B et al.Risk of acute myocardial infarction with NSAIDs in real world use: Bayesian meta-analysis of individual patient data.BMJ. 2017; 357: j1909Crossref PubMed Scopus (327) Google Scholar Nevertheless, the use of NSAIDs in the perioperative period of cardiac surgery has not been associated with myocardial injuries. Our study presented limitations related to its declarative nature, such as respondent selection bias, reporter bias linked to the purely declarative nature of the survey, and difficulty in generalizing data to actual practice and to other healthcare systems. In addition, the number of respondents was relatively low, with a response rate of only 13%. Nevertheless, it demonstrated that physicians declared to use NSAIDs during cardiac perioperative settings. Because of the lack of robust trials on this particular topic, this survey emphasized the need to perform further prospective studies to explore the safety, efficacy, risks, and benefits of NSAID use in the cardiac surgical population. None. The authors thank the ARCOTHOVA society for its help in dissemination of the survey. Download .docx (.02 MB) Help with docx files