Nonsteroidal Anti-Inflammatory Drugs as Part of a Multimodal Postoperative Pain Management Strategy in Patients Undergoing Cardiac Surgery: A Meta-Analysis of 11 Randomized Clinical Trials

Background: Effective and safe pain management is crucial for optimal recovery after cardiac surgery. Traditionally, opioids have been the mainstay for postoperative pain control, but their negative health effects have led to a recent shift toward multimodal analgesia to minimize opioid use. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been controversial owing to concerns about bleeding, acute kidney injury (AKI), graft patency, and cardiovascular risks. Despite these concerns, many perioperative teams continue to use NSAIDs alongside opioids as part of multimodal analgesia. This meta-analysis evaluated the efficacy and safety of NSAIDs as a multimodal pain management tool following cardiac surgery. Methods: An electronic search was conducted on November 15, 2024, using PubMed, Scopus, Web of Science, Embase, and Cochrane databases. Only controlled trials that combined NSAIDs with opioids for pain management following cardiac surgeries were included. The primary outcome was the visual analog scale (VAS), a 0 to 10 scale measuring pain intensity assessed at 6, 12, 18, 24, and 48 hours. Total opioid consumption was measured at 6, 12, 24, and 48 hours. Secondary outcomes included myocardial infarction, atrial fibrillation, kidney function, gastrointestinal bleeding, nausea, and vomiting. The mean difference (MD) was used for continuous outcomes, and the odds ratio (OR) was used for dichotomous outcomes. A random-effects model was applied for the analysis. Results: Out of the 1,194 articles screened, 11 articles, totaling 1,463 patients, were included in the meta-analysis. The NSAID group demonstrated significantly lower VAS scores at the 12-hour (MD, -1.19, 95% confidence interval [CI], -1.83 to -0.56; p < 0.001), 24-hour (MD, -0.61; 95% CI, -0.97 to -0.24; p = 0.001), 18-hour (MD, -1.43; 95% CI, -2.58 to -0.28; p = 0.01), and 48-hour (MD, -0.68; 95% CI, -0.87 to -0.49; p < 0.001) time points. However, no significant differences in VAS scores were observed at the 6-hour mark. Regarding opioid consumption, the NSAID group demonstrated significantly lower opioid consumption at the 24-hour (MD, -8.10; 95% CI, -10.60 to -5.61; p < 0.001) and 48-hour (MD, -7.13; 95% CI, -12.44 to -1.82; p = 0.009); however, no differences were observed at the 6-hour and 12-hour marks. Finally, there were no significant differences between the NSAID and control groups in the incidence of gastrointestinal bleeding, atrial fibrillation, myocardial infarction, or AKI. Conclusions: NSAID use was associated with modestly reduced VAS scores at 12, 18, 24, and 48 hours, while opioid consumption was significantly lower at 24 and 48 hours postoperatively. Short-term NSAID use can be effective in reducing pain and opioid requirements. Although no significant difference in complications was observed, the analysis was limited by small sample sizes. More extensive randomized controlled trials are needed to assess the effectiveness and safety of NSAIDs as part of a multimodal analgesic strategy.