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Weinberg L, Johnston S, Fletcher L, Caragata R, Hazard RH, Le P, Karp J, Carp B, Sean Yip SW, Walpole D, Shearer N, Neal-Williams T, Nicolae R, Armellini A, Matalanis G, Seevanayagam S, Bellomo R, Makar T, Pillai P, Warrillow S, Ansari Z, Koshy AN, Lee DK, Yii M. Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study. J Cardiothorac Surg 2024; 19:375. [PMID: 38918868 PMCID: PMC11202251 DOI: 10.1186/s13019-024-02935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/15/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting. METHODS This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications. RESULTS We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups. CONCLUSION Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA. TRIALS REGISTRATION The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).
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Affiliation(s)
| | - Samuel Johnston
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Luke Fletcher
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - Riley H Hazard
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Peter Le
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Jadon Karp
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Bradly Carp
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - Dominic Walpole
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
| | | | | | - Robert Nicolae
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Melbourne, Australia
| | - Siven Seevanayagam
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia
| | - Timothy Makar
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Param Pillai
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, Australia
| | - Ziauddin Ansari
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Michael Yii
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, Australia
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Edwards JN, Whitney MA, Smith BB, Fah MK, Buckner Petty SA, Durra O, Sell-Dottin KA, Portner E, Wittwer ED, Milam AJ. The role of methadone in cardiac surgery for management of postoperative pain. BJA OPEN 2024; 10:100270. [PMID: 38560623 PMCID: PMC10978480 DOI: 10.1016/j.bjao.2024.100270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
Abstract
Background This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. Methods Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). Results Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0-POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07-5.12), 6.82 (IQR=3.52-12.98), and 7.0 (IQR=3.82-12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups. Conclusions Intraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.
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Affiliation(s)
- Jordan N. Edwards
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | | | - Bradford B. Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Megan K. Fah
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Omar Durra
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | - Erica Portner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erica D. Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam J. Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
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Ibekwe SO, Everett L, Mondal S. Methadone Should Not Be Used in Cardiac Surgery as Part of Enhanced Recovery After Cardiac Surgery Protocol. J Cardiothorac Vasc Anesth 2024; 38:1272-1274. [PMID: 38503627 DOI: 10.1053/j.jvca.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 03/21/2024]
Affiliation(s)
| | - Lauren Everett
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Chen YH, Sadhasivam S, DeMedal S, Visoiu M. Short-acting versus long-acting opioids for pediatric postoperative pain management. Expert Rev Clin Pharmacol 2023; 16:813-823. [PMID: 37531096 PMCID: PMC10529420 DOI: 10.1080/17512433.2023.2244417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article. AREAS COVERED Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population. EXPERT OPINION Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Spencer DeMedal
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mihaela Visoiu
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
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5
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Tchen S, Bhatt R, Peppard W, Szabo A, Dong H, Morris R, Trevino CM. Quantifying the impact of reduced opioid use in patients after emergency laparotomy. Surgery 2023; 173:1499-1507. [PMID: 36948914 DOI: 10.1016/j.surg.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/05/2023] [Accepted: 02/11/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Emergency laparotomies have high rates of morbidity and mortality. The evaluation and management of pain are crucial, as poorly managed pain may contribute to postoperative complications and increase the risk of mortality. This study aims to describe the relationship between opioid use and opioid-related adverse effects and identify what constitutes appropriate dose reductions to elicit clinically relevant benefits. METHODS This was a retrospective, observational study of patients presenting for emergency laparotomy due to trauma from 2014 to 2018. The primary objective was to define clinical outcomes that may be significantly affected by changes in milligrams of morphine equivalent during the first 72 hours postoperatively; additionally, we sought to quantify the approximate differences in morphine equivalent that correlate with clinically meaningful outcomes such as hospital length of stay, pain scores, and time to first bowel movement. For descriptive summaries, patients were categorized into low, moderate, and high groups based on morphine equivalent requirements of 0 to 25, 25 to 50, and >50, respectively. RESULTS A total of 102 (35%), 84 (29%), and 105 (36%) patients were stratified into the low, moderate, and high groups, respectively. Mean pain scores for postoperative days 0 to 3 (P = .034), time to first bowel movement (P = .002), and nasogastric tube duration (P = .003) were the clinical outcomes found to be significantly associated with morphine equivalent. Estimated clinically significant reductions in morphine equivalent for these outcomes ranged from 194 to 464. CONCLUSION Clinical outcomes, such as pain scores, and opioid-related adverse effects, such as time to first bowel movement and nasogastric tube duration, may be linked with the amount of opioids used.
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Affiliation(s)
| | - Rootvij Bhatt
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
| | - William Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Aniko Szabo
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Huaying Dong
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Boisvert-Plante V, Poulin-Harnois C, Ingelmo P, Einhorn LM. What we know and what we don't know about the perioperative use of methadone in children and adolescents. Paediatr Anaesth 2023; 33:185-192. [PMID: 36281540 PMCID: PMC10416808 DOI: 10.1111/pan.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023]
Abstract
Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu-opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length-of-stay, and the incidence of some opioid-related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure-specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors.
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Affiliation(s)
| | - Christelle Poulin-Harnois
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
| | - Pablo Ingelmo
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Complex Pain Centre, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Lisa M. Einhorn
- Department of Anesthesiology, Pediatric Division, Duke University School of Medicine, Durham, North Carolina, United States
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Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline. Cardiol Young 2022; 32:1881-1893. [PMID: 36382361 DOI: 10.1017/s1047951122003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. METHODS A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. RESULTS 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. CONCLUSIONS Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.
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8
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Carlson A, Pham D, Price C, Reisch J, Iskander I, Ambardekar A. Novel use of methadone intraoperatively in pediatric burn patients. J Burn Care Res 2022; 43:1294-1298. [PMID: 35245371 DOI: 10.1093/jbcr/irac022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn injury in children can cause severe and chronic physical and mental sequelae. Opioids are a mainstay in burn pain management but increasing utilization in this country has led to concern for their continued use and potential for dependence. Methadone is a long-acting analgesic that targets the N-methyl-D-aspartate (NMDA) receptor in addition to the mu opioid receptor and has benefit in adult burn patients. However, its use in the pediatric burn population has been less robustly studied. This is a retrospective cohort study at a single Level 1 Burn Center whose primary aim is to compare opioid utilization 36 hours postoperatively between pediatric burn patients who received intraoperative, intravenous methadone and those who did not. Secondary aim was to describe differences in methadone-related complications between the cohorts. There was decreased opioid utilization measured by median morphine equivalents per kilogram (ME/kg) postoperatively in the methadone cohort compared to the control cohort (0.54mg/kg v. 0.77mg/kg, p = 0.18). No adverse events were noted upon chart review. The data suggests methadone use is beneficial in pediatric burn patients, but further prospective studies are warranted on a larger population.
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Affiliation(s)
| | - David Pham
- UT Southwestern Medical Center, Dallas, TX
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9
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Wang DJ, Song P, Nault KM. Impact of intraoperative methadone use on postoperative opioid requirements after cardiac surgery. Am J Health Syst Pharm 2021; 79:636-642. [PMID: 34874991 DOI: 10.1093/ajhp/zxab459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Inadequate pain control after cardiac surgery increases postoperative morbidity. Increasing evidence suggests that perioperative intravenous (IV) methadone results in improved analgesia. This study evaluated the effect of intraoperative IV methadone on postoperative opioid requirements and surgical recovery. METHODS A retrospective review of patients undergoing coronary artery bypass graft (CABG), valvular surgery or both between April 2017 and August 2018 was conducted. Patients were separated into a usual care cohort of those who received short-acting opioids (ie, IV fentanyl, hydromorphone, or morphine) alone or a methadone cohort of those who received IV methadone plus short-acting opioids. Opioid requirements were assessed within the first 24 hours of surgery (postoperative day [POD] 0) and 25 to 48 hours after surgery (POD 1) as oral morphine milligram equivalents (MME). Postoperative pain scores, adjunctive analgesia, time to extubation, use of noninvasive respiratory support (continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]), and intensive care unit (ICU) and hospital length of stay (LOS) were also evaluated. RESULTS A total of 117 patients were evaluated (methadone cohort, n = 52; usual care cohort, n = 65). Median cumulative intraoperative opioid consumption was less in the methadone cohort (150 MME vs 314.1 MME; P < 0.0001). The methadone cohort required 44% fewer MME than the usual care cohort on POD 0 (median MME, 15.8 vs 36; P = 0.025), with low and not significantly different opioid use in both cohorts on POD 1 (15.5 MME vs 7.5 MME; P = 0.47). Weight-based methadone dosing ranged from 0.1 to 0.4 mg/kg (mean, 0.22 mg/kg). There were no significant differences in pain scores, time to extubation, use of CPAP or BiPAP, or ICU and hospital LOS. CONCLUSION Intraoperative IV methadone in cardiac surgery patients was safe and significantly reduced intraoperative and postoperative opioid requirements on POD 0.
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Affiliation(s)
- David J Wang
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
| | - Pingping Song
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Katharine M Nault
- Department of Pharmacy, Lahey Hospital & Medical Center, Burlington, MA, USA
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Froehling NM, Martin JA, Miles MVP, Wilson AW, Byers B, LeMaster D, Salazar Ó, Bhattacharya SD, Smith LA. Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum. Am Surg 2021:31348211054066. [PMID: 34743569 DOI: 10.1177/00031348211054066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE. METHODS A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food. RESULTS Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55 MME/kg while patients in the MM + M group received 1.16 ± .44 MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food. DISCUSSION Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.
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Affiliation(s)
- Nadia M Froehling
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - James A Martin
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - M Victoria P Miles
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - Andrew W Wilson
- Department of Orthopedic Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - Brynn Byers
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - David LeMaster
- Anesthesiology Consultants Exchange of Erlanger Hospital, Chattanooga, TN, USA
| | - Óscar Salazar
- Anesthesiology Consultants Exchange of Erlanger Hospital, Chattanooga, TN, USA
| | - S Dave Bhattacharya
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
| | - Lisa A Smith
- Department of Surgery, 70274University of Tennessee College of Medicine Chattanooga, TN, USA
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Lobova VA, Roll JM, Roll MLC. Intraoperative Methadone Use in Cardiac Surgery: A Systematic Review. PAIN MEDICINE 2021; 22:2827-2834. [PMID: 34487175 DOI: 10.1093/pm/pnab269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/30/2021] [Accepted: 08/28/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the effects of intraoperative methadone to standard of care opioids such as fentanyl and morphine on pain scores, opioid consumption, and adverse effects in adults undergoing cardiothoracic surgery. METHODS The literature was reviewed on PubMed, Embase, Cochrane Library, and Google Scholar, followed by a manual search using reference lists of the identified articles. Search terms included a combination of intraoperative methadone, methadone, and cardiac surgery. Our review includes four studies published between 2011 and 2020. Quality assessment of the studies was performed. RESULTS The initial search identified 715 articles with 461 duplicates removed, and 236 eliminated based on inclusion and exclusion criteria. Eighteen articles underwent full-text review. Four studies evaluating a total of 435 patients with various cardiothoracic procedures were included in this review. We found that intraoperative methadone decreases acute postoperative pain and reduces postoperative opioid consumption in the first 24 postoperative hours in patients who received 0.1-0.3 mg/kg intraoperative methadone in comparison to morphine and fentanyl. No difference was found in adverse effects between the groups. Quality assessment of the studies showed a low risk of bias in three of the randomized controlled trials and a high risk of bias in the retrospective review because of the baseline confounding bias in the study design. CONCLUSIONS Intraoperative methadone use reduces acute postoperative pain and lowers opioid consumption in comparison to morphine and fentanyl. Initial results suggest that methadone may be an equivalent opioid to be administered during cardiothoracic procedures to reduce acute post-surgical pain, though further research is warranted.
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Affiliation(s)
- Veronika A Lobova
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington
| | - John M Roll
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington.,Department of Community and Behavioral Health, Program of Excellence in the Addictions, Washington State University, Spokane, Washington
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12
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Methadone: applications in pediatric anesthesiology and critical care medicine. J Anesth 2021; 35:130-141. [PMID: 33432486 DOI: 10.1007/s00540-020-02887-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
Like morphine, methadone is a pure agonist at the µ opioid receptor. However, in distinction to morphine which has an elimination half-life of 2-3 h, methadone has an elimination half-life of 24-36 h. In addition to its effects at the µ opioid receptor, methadone is an antagonist at the N-methyl-D-aspartate (NMDA) receptor and also inhibits the reuptake of the neurotransmitters, serotonin and norepinephrine, in the central nervous system. Given its long half-life and high oral bioavailability, methadone has had a primary role in the outpatient treatment of patients with a history of opioid abuse or addiction. However, its unique pharmacology and cellular effects make it a valuable agent in the treatment of both acute and chronic pain of various etiologies. The following manuscript reviews the pharmacologic properties of methadone and discusses its clinical applications in the practice of pediatric anesthesiology and pediatric critical care medicine.
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Ha B, Usman AA, Augoustides JG. Minimally Invasive Cardiac Surgery-Identifying Opportunities for Further Improvement in the Quality of Postoperative Patient Recovery. J Cardiothorac Vasc Anesth 2020; 34:3231-3233. [PMID: 32950344 DOI: 10.1053/j.jvca.2020.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Ali Usman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Burtoft MA, Gillespie SM, Laporta ML, Wittwer ED, Schroeder DR, Sprung J, Weingarten TN. Postoperative Nausea and Vomiting and Pain After Robotic-Assisted Mitral Valve Repair. J Cardiothorac Vasc Anesth 2020; 34:3225-3230. [PMID: 32732099 DOI: 10.1053/j.jvca.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the rate and clinical factors associated with postoperative nausea and vomiting (PONV) and severe pain after robotic-assisted mitral valve repair. DESIGN Retrospective chart review. SETTING Major quaternary academic medical center. PARTICIPANTS Adult patients undergoing robotic-assisted mitral valve repair from May 5, 2018 through September 13, 2019. INTERVENTIONS Participant electronic medical records were abstracted for clinical characteristics, PONV within the first 72 postoperative hours, episodes of severe pain (defined as pain score ≥7 using an 11-point numerical pain rating scale), and opioid use within the first 24 postoperative hours. Multivariate analyses were performed. MEASUREMENTS AND MAIN RESULTS Of 124 participants, PONV was noted in 83 (67%; 95% confidence interval [CI] 58%-75%) patients and severe pain in 96 (77%, 95% CI 69%-84%) patients. The median (interquartile range) time to PONV was 6.1 (3.7-14.7) hours. After adjusting for age, sex, and duration of surgery, pre-incisional use of methadone was associated with reduced risk for severe pain (odds ratio 0.40 [95% CI 0.16-0.99]; p = 0.048) and a lower 24-postoperative hour opioid requirement (estimate -29.0 mg intravenous morphine equivalents [95% CI -46.7 to -11.3]; p = 0.006). However, methadone was not associated with a reduction of the cumulative opioid dose (intraoperative and 24-hour postoperative opioid dose; p = 0.248). Both severe pain and PONV were associated with longer hospital stay. CONCLUSION PONV and severe pain are common after robotic-assisted mitral valve repair. Peri-incisional methadone is associated with a modest decrease in the severe pain rate but without a reduction in opioid dose or hospital stay.
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Affiliation(s)
- Melissa A Burtoft
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Shane M Gillespie
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Erica D Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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