2026 Southeastern Residency Conference

Graham Anglin, Adam L. Wiss 
Ascension Saint Thomas Hospital West - Nashville, TN 

Introduction: Multimodal analgesia has become a cornerstone of perioperative pain management, reducing opioid exposure and associated adverse effects. At Ascension Saint Thomas Hospital West (ASTHW), continuous intravenous lidocaine infusions have been utilized to improve postoperative pain control in minimally invasive direct coronary artery bypass (MIDCAB) procedures. However, safety concerns and intensive care unit (ICU) monitoring requirements limit their broader use. In June 2022, liposomal bupivacaine, a long-acting local anesthetic, was added to the formulary as an alternative strategy for prolonged analgesia. While studies have shown mixed outcomes depending on surgical type and administration technique, data specific to cardiothoracic surgery remain limited. The objective of this study was to compare intravenous lidocaine and liposomal bupivacaine for postoperative pain management in patients undergoing MIDCAB. 

Methods: This single-center retrospective chart review included adults who underwent MIDCAB at ASTHW between June 2022 and July 2025. Patients received either a single dose of liposomal bupivacaine or a continuous intravenous lidocaine infusion for postoperative analgesia. Exclusion criteria included substance use disorder, concurrent buprenorphine, methadone, or naltrexone therapy; pregnancy, incarceration, surgical re-exploration for bleeding within 24 hours of MIDCAB, or use of mechanical circulatory support. The primary outcome was postoperative opioid use, reported as morphine milligram equivalents (MME) within 72 hours. Secondary outcomes included postoperative pain scores, ICU and total hospital length of stay (LOS), and incidence of adverse effects such as hypotension, bradycardia, arrhythmia, and nausea. 

Results: One-hundred fifty patients were included in the study (intravenous lidocaine = 75; liposomal bupivacaine = 75). Baseline characteristics were comparable, with both groups consisting predominantly of Caucasian males (median age 66 years). All patients received multimodal analgesia; however, the intravenous lidocaine group had higher use of methocarbamol (17% vs 3%, p = 0.007) and erector spinae plane blocks (77% vs 1%, p < 0.001).  There was no statistically significant difference in postoperative MME usage between the intravenous lidocaine group and liposomal bupivacaine group on postoperative day 0/1 (61 vs. 72; p = 0.659), postoperative day 2 (23 vs. 23; p = 0.467) or postoperative day 3 (8 vs. 8 ; p = 0.92). The groups were also similar in postoperative pain scores, hospital and ICU LOS, and incidence of adverse effects.

Conclusion: In this study evaluating postoperative analgesia following MIDCAB surgery, patients who received continuous infusion of intravenous lidocaine had comparable postoperative opioid consumption to those who received a single administration of liposomal bupivacaine with no difference in adverse events between groups. While either of these analgesia strategies may be effective in patients undergoing MIDCAB, further investigation is warranted to determine the role other treatments (i.e., local anesthetic blocks and muscle relaxers) may have had on outcomes in our population.