A 2007 AHA Scien- tific statement presented a stepped-care approach to the management of musculoskeletal pain in patients with or at risk for coronary artery disease (CAD), with the goal of limiting the use of these agents to patients in whom safer therapies fail.47 In patients hospitalized with unstable angina (UA) and non ST-elevation myocardial infarction (NSTEMI), these agents should be discontinued promptly and reinstituted later according to the stepped-care approach.48 In the setting of cardiac surgery, nonsteroidal anti- inflammatory agents previously were used for perioperative analgesia. A meta-analysis of 20 trials of patients undergoing thoracic or cardiac surgery, which evaluated studies published before 2005, reported significant reductions in pain scores, with no increase in adverse outcomes.49 Subsequently, 2 RCTs, both studying the oral cyclooxygenase-2 inhibitor valdecoxib and its intravenous prodrug, parecoxib, reported a higher incidence of sternal infections in 1 trial and a significant increase in adverse cardiovascular events in the other.26,27 On the basis of the results of these 2 studies (as well as other nonsurgical reports of increased risk with cyclooxygenase-2 selective agents), the U.S. Food and Drug Administration in 2005 issued a black box warning for all nonsteroidal anti-inflammatory agents (except aspirin) immediately after CABG.50 The concurrent administra- tion of ibuprofen with aspirin has been shown to attenuate the latter s inhibition of platelet aggregation, likely because of competitive inhibition of cyclooxygenase at the platelet-receptor Observational analyses in patients undergoing noncardiac surgery have shown a significant reduction in perioperative death with the use of checklists, multidisciplinary surgical care, intraoperative time-outs, postsurgical debriefings, and other communication strategies.14,15 Such methodology is being used increasingly in CABG patients.12 14 In contrast to extensive literature on the role of the surgeon in determining outcomes with CABG, limited data on the influence of the anesthesiologist are available. 