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Cata JP, Zaidi Y, Guerra-Londono JJ, Kharasch ED, Piotrowski M, Kee S, Cortes-Mejia NA, Gloria-Escobar JM, Thall PF, Lin R. Intraoperative methadone administration for total mastectomy: A single center retrospective study. J Clin Anesth 2024; 98:111572. [PMID: 39180867 DOI: 10.1016/j.jclinane.2024.111572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 06/15/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Breast cancer is the most frequent type of cancer and the second leading cause of cancer-related mortality in women. Mastectomies remain a key component of the treatment of non-metastatic breast cancer, and strategies to treat acute postoperative pain, a complication affecting nearly all patients undergoing surgery, continues to be an important clinical challenge. This study aimed to determine the impact of intraoperative methadone administration compared to conventional short-acting opioids on pain-related perioperative outcomes in women undergoing a mastectomy. METHODS This single-center retrospective study included adult women undergoing total mastectomy. The primary outcome of this study was postoperative pain intensity on day 1 after surgery. Secondary outcomes included perioperative opioid consumption, perioperative non-opioid analgesics use, duration of surgery and anesthesia, time to extubation, pain intensity in the postanesthesia care unit (PACU), anti-emetic use in PACU, and length of stay in hospital. We used the propensity score-based nearest matching with a 1:3 ratio to balance the patient baseline characteristics. RESULTS 133 patients received methadone, and 2192 patients were treated with short-acting opioids. The analysis demonstrated that methadone was associated with significantly lower intraoperative and postoperative opioid consumption as measured by oral morphine equivalents and lower average pain intensity scores in the postanesthesia care unit. Moreover, methadone was also shown to reduce the use of non-opioid analgesia during surgery. CONCLUSION Our study suggests that the unique pharmacological properties of methadone, including a short onset of action when given intravenously, long-acting pharmacokinetics, and multimodal effects, are associated with better acute pain management after a total mastectomy.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America; Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America; Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States of America.
| | - Yusuf Zaidi
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Juan Jose Guerra-Londono
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America; Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, NC, United States of America
| | - Matthew Piotrowski
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Spencer Kee
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Nicolas A Cortes-Mejia
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jose Miguel Gloria-Escobar
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Peter F Thall
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States of America
| | - Ruitao Lin
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America
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Foglia R, Yan J, Dizdarevic A. Methadone and Buprenorphine in the Perioperative Setting: A Review of the Literature. Curr Pain Headache Rep 2024; 28:1105-1111. [PMID: 38907792 DOI: 10.1007/s11916-024-01286-8] [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] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the most recent literature and guidelines regarding perioperative methadone and buprenorphine use. RECENT FINDINGS Surgical patients taking methadone and buprenorphine are being encountered more frequently in the perioperative period, and providers are becoming more familiar with their pharmacologic properties, benefits as well as precautions. Recommendations pertaining to buprenorphine therapy in the perioperative settings have changed in recent years, owing to more clinical and basic science research. In addition to their use in chronic pain and opioid use disorders, they can also be initiated for acute postoperative pain indications, in select patients and situations. Methadone and buprenorphine are being more commonly prescribed for pain management and opioid use disorder, and their continuation during the perioperative period is generally recommended, to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain. Additionally, both may be initiated safely and effectively for acute pain management during and after the operating room period.
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Affiliation(s)
- Ralph Foglia
- Columbia University Medical Center, New York, NY, USA
| | - Jasper Yan
- Columbia University Medical Center, New York, NY, USA
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LaColla L, Nanez MA, Frabitore S, Lavage DR, Warraich N, Luke C, Sultan I, Sadhasivam S, Subramaniam K. Intravenous Methadone versus Intrathecal Morphine as Part of an Enhanced Recovery After Cardiac Surgery Protocol on Postoperative Pain and Outcomes: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:2314-2323. [PMID: 39043493 DOI: 10.1053/j.jvca.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/23/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES Evaluate the effect of intravenous (IV) methadone versus intrathecal morphine (ITM) within an Enhanced Recovery After Cardiac Surgery (ERACS) pathway on postoperative pain and outcomes (length of hospital stay and postoperative complications) after cardiac surgery. DESIGN Retrospective cohort study. SETTING Two tertiary academic medical institutions within the same health system. PARTICIPANTS Eligible 289 adult patients undergoing elective cardiac surgery with an enhanced recovery pathway from January 2020 through July 2021. INTERVENTIONS Patients were administered ITM (0.25 mg) or IV methadone (0.1 mg/kg) if ITM was contraindicated. All patients were enrolled in an ERACS pathway using current Enhanced Recovery After Surgery society guidelines. MEASUREMENTS AND MAIN RESULTS Primary outcome measures included postoperative pain scores and opioid consumption measured as oral morphine equivalents. We analyzed patient demographics, procedural factors, intraoperative medications, and outcomes. Adjusted linear mixed models were fit to analyze associations between intervention and pain outcomes. ITM was associated with decrease in pain scores on postoperative day 0 after adjusting for clinical variables (average marginal effect, 0.49; 95% confidence interval, 0.002-0.977; p = 0.049). No difference in opioid consumption could be demonstrated between groups after adjusting for postoperative day and other variables of interest. CONCLUSIONS ITM when compared with IV methadone was associated with a decrease in pain scores without any difference in opioid consumption after elective cardiac surgery. Methadone can be considered as a safe and effective alternative to ITM for ERACS protocols. Future large prospective studies are needed to validate this finding and further improve analgesia and safety.
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Affiliation(s)
- Luca LaColla
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maria A Nanez
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stephen Frabitore
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Danielle R Lavage
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nav Warraich
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Charles Luke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Ramaiah VK, Kharasch ED. Methadone and Enhanced Recovery After Surgery: Concepts and Protocols. Anesth Analg 2024; 139:670-674. [PMID: 38295148 PMCID: PMC11289168 DOI: 10.1213/ane.0000000000006790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Vijay K Ramaiah
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Koch R, Witkam R, van Eijk LT, Bruhn J. Triple Anesthesia: Combining Sevoflurane, Propofol, and Remimazolam for General Anesthesia in a Case Series. Cureus 2024; 16:e66737. [PMID: 39268305 PMCID: PMC11391167 DOI: 10.7759/cureus.66737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2024] [Indexed: 09/15/2024] Open
Abstract
There is an ongoing quest for an ideal uniform anesthesia regimen that adequately covers all nociceptive stimuli preventing hypertension and tachycardia while minimizing hypotension and the need for antihypotensive drugs. Recently, the ultra-short-acting benzodiazepine remimazolam was approved for the induction and maintenance of general anesthesia. Combining remimazolam with sevoflurane and propofol may combine the antiemetic properties of propofol, the depressing (immobilizing) effect on spinal motor neurons of sevoflurane, and the hemodynamic stability afforded by remimazolam, making it an attractive addition to the armamentarium of anesthetic agents. We describe five patients in whom general anesthesia was maintained with this triple combination, along with multimodal analgesia. All patients maintained hemodynamic stability at sufficient hypnotic depth, with no observable movement during surgery or episodes of cardiac arrhythmias.
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Affiliation(s)
- Rebecca Koch
- Anesthesiology, Radboud University Medical Center, Nijmegen, NLD
| | - Richard Witkam
- Anesthesiology, Radboud University Medical Center, Nijmegen, NLD
| | - Lucas T van Eijk
- Anesthesiology, Radboud University Medical Center,, Nijmegen, NLD
| | - Jörgen Bruhn
- Anesthesiology, Radboud University Medical Center, Nijmegen, NLD
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Kharasch ED. Intraoperative Methadone and Postoperative Anesthesia Care Unit Outcomes: A Retrospective Cohort Analysis. Anesthesiology 2024; 141:408-410. [PMID: 38787911 PMCID: PMC11233225 DOI: 10.1097/aln.0000000000005034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Affiliation(s)
- Evan D Kharasch
- Duke University School of Medicine, Durham, North Carolina; Bermaride, LLC.
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Azamfirei R, Procaccini D, Lobner K, Kudchadkar SR. The Effects of Intraoperative Methadone on Postoperative Pain Control in Pediatric Patients: A Scoping Review. Anesth Analg 2024; 139:263-271. [PMID: 37285308 DOI: 10.1213/ane.0000000000006548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Inadequate perioperative pain control has deleterious effects on children's development and can lead to heightened pain experiences and the avoidance of future medical procedures. Reports of perioperative use of methadone in children are increasing, as it has a favorable pharmacodynamic profile; however, the effectiveness of methadone in reducing postoperative pain has not been established. We, therefore, aimed to provide a scoping review of the literature comparing the effect of intraoperative methadone versus other opioids on postoperative opioid consumption, pain scores, and adverse events in pediatric patients. We identified studies in PubMed, Scopus, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to January 2023. Postoperative opioid consumption, pain scores, and adverse events were extracted for analysis. We screened 1864 studies, of which 83 studies were selected for full-text review. Five studies were included in the final analysis. Postoperative opioid consumption was decreased overall in children who received methadone compared to those who did not. The majority of studies indicated that methadone was superior to other opioids in reported pain scores, while the frequency of adverse events was similar between the groups. Although the data reviewed highlight a potential benefit of intraoperative methadone in pediatric patients, 4 of the 5 studies had serious methodological concerns. Thus, we cannot make strong recommendations for the regular use of methadone in the perioperative setting at this time. Our results highlight the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse pediatric surgical populations.
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Affiliation(s)
- Razvan Azamfirei
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- "George Emil Palade" University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Dave Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicin, Baltimore, Maryland
| | - Sapna R Kudchadkar
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Boesl MA, Brown N, Bleicher J, Call T, Lambert DH, Lambert LA. Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC. Ann Surg Oncol 2024; 31:3742-3749. [PMID: 38300404 DOI: 10.1245/s10434-024-14900-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/29/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone. METHODS A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted. RESULTS A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess. CONCLUSIONS CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.
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Affiliation(s)
- Markus A Boesl
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Noah Brown
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Josh Bleicher
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Tyler Call
- Department of Anesthesiology, University of Utah Health, Salt Lake City, UT, USA
| | - Donald H Lambert
- Department of Anesthesiology, Boston University Medical Center, Boston, MA, USA
| | - Laura A Lambert
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA.
- Department of Surgical Oncology, Huntsman Cancer Institute, Salt Lake City, UT, USA.
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Carlé N, Nikolajsen L, Uhrbrand CG. Respiratory Depression Following Intraoperative Methadone: A Retrospective Cohort Study. Anesth Analg 2024:00000539-990000000-00825. [PMID: 38814334 DOI: 10.1213/ane.0000000000007018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Methadone is used as a perioperative analgesic in the management of postoperative pain. Despite positive outcomes from randomized trials favoring methadone, concerns about its safety persist, particularly regarding respiratory depression (RD) and excessive sedation. In this study, we compared the incidence of naloxone administration between patients administered intraoperative methadone and those administered intraoperative morphine as a measure of severe RD. Time spent at the postanesthesia care unit (PACU) was used as a proxy variable for excessive sedation. METHODS This was a retrospective cohort study including all patients aged ≥18 years who underwent surgery between March 2019 and March 2023 at Aarhus University Hospital, Denmark. We assessed the association between intraoperative administration of either methadone or morphine and postoperative naloxone administration within the first 24 hours using logistic regression (primary outcome). An analogous linear regression model was used for the secondary outcome of time spent in the PACU after surgery. Patients were weighted using propensity scores to adjust for potential confounding variables. RESULTS A total of 14,522 patients were included in the analysis. Among the 2437 patients who received intraoperative methadone, 15 (0.62%) patients received naloxone within the first 24 hours after surgery compared to 68 of 12,0885 (0.56%) who received intraoperative morphine. No statistical difference was observed in the odds of naloxone administration between patients administered methadone or morphine (adjusted odds ratio 95% confidence interval [CI], 1.21 [0.40-2.02]). Patients who were administered intraoperative methadone had a mean PACU length of stay (LOS) of 334 minutes (standard deviation [SD], 382) compared to 195 minutes (SD, 228) for those administered intraoperative morphine. The adjusted PACU LOS of patients administered intraoperative methadone was 26% longer compared to those administered intraoperative morphine (adjusted ratio of the geometric means 95% CI, 1.26 [1.22-1.31]). CONCLUSIONS The incidence of naloxone administration to treat severe RD was low. No difference was observed in the odds of naloxone administration to treat severe RD between patients administered intraoperative methadone or intraoperative morphine. Intraoperative methadone was associated with longer stays at the PACU; however, this result should be interpreted with care. Our findings suggest that intraoperative methadone has a safety profile comparable to that of morphine with regard to severe RD.
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Affiliation(s)
- Nicolai Carlé
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Nikolajsen
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Camilla G Uhrbrand
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Lumsden S, Kharasch ED, Speer B, Kwater A, Gan TJ, Cata JP. Intraoperative Methadone Administration Is Not Associated With an Increase in Perioperative Use of Naloxone: A Retrospective Study. Anesth Analg 2024; 138:1145-1147. [PMID: 38195080 DOI: 10.1213/ane.0000000000006815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Affiliation(s)
- Sarah Lumsden
- From the Department of Anesthesiology, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Bryce Speer
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Andrzej Kwater
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Tong Joo Gan
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, Texas
- Anesthesiology and Surgical Oncology Research Group, Houston, Texas
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Green KW, Popovic G, Baitch L. Intraoperative methadone for day-case gynaecological laparoscopy: A double-blind, randomised controlled trial. Anaesth Intensive Care 2024; 52:168-179. [PMID: 38649297 PMCID: PMC11071594 DOI: 10.1177/0310057x231214551] [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] [Indexed: 04/25/2024]
Abstract
Optimal pain relief in day-case surgery is imperative to patient comfort and timely discharge from hospital. Short-acting opioids are commonly used for analgesia in modern anaesthesia, allowing rapid recovery after surgery. Plasma concentration fluctuations from repeated dosing of short-acting opioids can cause patients to oscillate between analgesia with potential adverse effects, and inadequate analgesia requiring rescue dosing. Methadone's unique pharmacology may offer effective and sustained analgesia with less opioid consumption, potentially reducing adverse effects. Using a double-blind, randomised controlled trial, we compared post-anaesthesia care unit opioid consumption between day-case gynaecological laparoscopy patients who received either intravenous methadone (10 mg), or short-acting opioids intraoperatively. The primary outcome was post-anaesthesia care unit opioid consumption in oral morphine equivalents. Secondary outcomes included total opioid consumption, discharge opioid consumption, pain scores (0-10) until discharge, adverse effects (respiratory depression, postoperative nausea and vomiting, excess sedation), and rate of admission. Seventy patients were randomly assigned. Patients who received methadone consumed on average 9.44 mg fewer oral morphine equivalents in the post-anaesthesia care unit than the short-acting group (18.02 mg vs 27.46 mg, respectively, 95% confidence interval 0.003 to 18.88, P = 0.050) and experienced lower postoperative pain scores at every time point, although absolute differences were small. There was no evidence of lower hospital or discharge opioid consumption. No significant differences between the methadone and short-acting groups in other outcomes were identified: respiratory depression 41.2% versus 31.4%, Padjusted >0.99; postoperative nausea and vomiting 29.4% versus 42.9%, Padjusted >0.99; overnight admission 17.7% versus 11.4%, Padjusted >0.99; excess sedation 8.82% versus 8.57%, Padjusted >0.99. This study provides evidence that, although modestly, methadone can reduce post-anaesthesia care unit opioid consumption and postoperative pain scores after day-case gynaecological laparoscopy. There were no significant differences in any secondary outcomes.
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Affiliation(s)
- Kyle W Green
- Albury Rural Clinical Campus, University of New South Wales, Albury, Australia
| | - Gordana Popovic
- UNSW Stats Central, University of New South Wales, Sydney, Australia
| | - Luke Baitch
- Albury Rural Clinical Campus, University of New South Wales, Albury, Australia
- Department of Anaesthesia, Albury Wodonga Health, Albury, Australia
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Chen YH, Xenitidis A, Hoffmann P, Matthews L, Padmanabhan SG, Aravindan L, Ressler R, Sivam I, Sivam S, Gillispie CF, Sadhasivam S. Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia. Expert Rev Clin Pharmacol 2024; 17:455-465. [PMID: 38626303 PMCID: PMC11116045 DOI: 10.1080/17512433.2024.2343915] [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: 09/09/2023] [Accepted: 04/12/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder. AREAS COVERED Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic. EXPERT OPINION The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.
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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, USA
| | | | - Paul Hoffmann
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leslie Matthews
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Ruth Ressler
- Department of Biochemistry and Molecular Biology, The College of Wooster, Wooster, Ohio, USA
| | - Inesh Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Sahana Sivam
- North Allegheny High School, Pittsburgh, Pennsylvania, USA
| | - Chase F. Gillispie
- Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia 25701
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Garcia S, Mali M, Grewal A. Pro: Methadone Should Be Used as a Part of Enhanced Recovery After Cardiac Surgery Protocol. J Cardiothorac Vasc Anesth 2024; 38:1268-1271. [PMID: 38458828 DOI: 10.1053/j.jvca.2024.02.022] [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: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Shelby Garcia
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mitali Mali
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Ashanpreet Grewal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Nunn KP, Velazquez AA, Bebawy JF, Ma K, Sinedino BE, Goel A, Pereira SM. Perioperative Methadone for Spine Surgery: A Scoping Review. J Neurosurg Anesthesiol 2024:00008506-990000000-00106. [PMID: 38624227 DOI: 10.1097/ana.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/08/2024] [Indexed: 04/17/2024]
Abstract
Complex spine surgery is associated with significant acute postoperative pain. Methadone possesses pharmacological properties that make it an attractive analgesic modality for major surgeries. This scoping review aimed to summarize the evidence for the perioperative use of methadone in adults undergoing complex spine surgery. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was performed using MEDLINE, CINAHL, Cochrane Library, Scopus, Embase, and Joanna Briggs between January 1946 and April 2023. The initial search identified 317 citations, of which 12 met the criteria for inclusion in the review. There was significant heterogeneity in the doses, routes of administration, and timing of perioperative methadone administration in the included studies. On the basis of the available literature, methadone has been associated with reduced postoperative pain scores and reduced postoperative opioid consumption. Though safety concerns have been raised by observational studies, these have not been confirmed by prospective randomized studies. Further research is required to explore optimal methadone dosing regimens, the potential synergistic relationships between methadone and other pharmacological adjuncts, as well as the potential long-term antinociceptive benefits of perioperative methadone administration.
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Affiliation(s)
- Kieran P Nunn
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Ahida A Velazquez
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - John F Bebawy
- Anesthesiology & Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kan Ma
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Bruno Erick Sinedino
- Discipline of Anesthesiology, Department of Surgery, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Akash Goel
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sergio M Pereira
- Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Razak A, Corman B, Servider J, Mavarez-Martinez A, Jin Z, Mushlin H, Bergese SD. Postoperative analgesic options after spine surgery: finding the optimal treatment strategies. Expert Rev Neurother 2024; 24:191-200. [PMID: 38155560 DOI: 10.1080/14737175.2023.2298824] [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: 06/03/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes. AREAS COVERED This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques. EXPERT OPINION Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.
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Affiliation(s)
- Alina Razak
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Benjamin Corman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - John Servider
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Ana Mavarez-Martinez
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Harry Mushlin
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
- Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
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16
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Burns ML, Hilliard P, Vandervest J, Mentz G, Josifoski A, Varghese J, Fisher C, Kheterpal S, Shah N, Bicket MC. Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution. JAMA Netw Open 2024; 7:e2351689. [PMID: 38227311 PMCID: PMC10792468 DOI: 10.1001/jamanetworkopen.2023.51689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/26/2023] [Indexed: 01/17/2024] Open
Abstract
Importance The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear. Objective To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories. Design, Setting, and Participants This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023. Main Outcomes and Measures The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs). Results Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques). Conclusions and Relevance In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.
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Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Paul Hilliard
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - John Vandervest
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Ace Josifoski
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Jomy Varghese
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Clark Fisher
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Nirav Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Prescribing Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor
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Le KDR, Hua J. Intravenous methadone in the management of acute postoperative pain in a chronic cancer pain patient: A case report and review of the literature. Clin Case Rep 2023; 11:e8332. [PMID: 38094140 PMCID: PMC10717171 DOI: 10.1002/ccr3.8332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 10/17/2024] Open
Abstract
Key Clinical Message The current landscape of literature highlights that there is insufficient well-powered and robust evidence to support the integration of intravenous methadone into current guidelines and frameworks in supporting the pain management of cancer patient with complex pain syndromes. However, there is preliminary evidence, both from the literature as well as this case study that highlights intravenous methadone may be efficaciously and safety used for the management of postoperative pain in cancer patients with chronic pain undergoing operative management. Further research is required to fully elucidate key considerations of integrating this medication into clinical practice including consideration into dosing, opioid conversion, tolerance, and safety. Abstract Methadone is a broad-spectrum analgesic with long duration of effect. Its multimodal mechanism of action, such as through effects on mu-opioid receptor and presynaptic N-methyl-D-aspartate receptors, has led to its current use in the management of opioid dependence in the community and in palliative care. These properties however make methadone appealing in the management of postoperative pain, particularly for patients with complex analgesic requirements. We report on an interesting case whereby intravenous methadone was effectively used for postoperative analgesia in a 56-year-old female with complex chronic pain secondary to a mucinous pelvic neoplasm of unclear primary who underwent palliative resection. Further, we review the literature surrounding usage of methadone in this setting to understand current challenges and barriers to implementation of methadone as an analgesia option for chronic pain patients following surgery. To do this, a case report and literature review was conducted in accordance to the CARE case report guidelines. The patient provided written consent for the de-identification and use of their medical information and data for the generation and publication of this case report. Our case report and literature review demonstrate there remains significant heterogeneity, unfamiliarity, and scarce use of intravenous methadone in the perioperative and postoperative space in the management of patients with complex pain regimens such as chronic cancer pain patients. Despite this, our case report and literature review highlight as a broad analgesic, intravenous methadone warrants consideration following more rigorous research and development of safe use guidelines into its use for this purpose.
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Affiliation(s)
- Khang Duy Ricky Le
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Surgical OncologyPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
- Geelong Clinical SchoolDeakin UniversityGeelongVictoriaAustralia
- Department of Medical EducationMelbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
| | - Jean Hua
- Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
- Department of PharmacyThe Royal Melbourne HospitalMelbourneVictoriaAustralia
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18
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Pedersen AK, Nygaard KH, Petersen SR, Specht K, Strøm T, Moos CM, Skjøt-Arkil H, Schønnemann JO. Adjusting perioperative methadone dose for elderly and fragile hip fracture patients (MetaHip-trial) - A statistical analysis plan for an adaptive dose-finding trial. Contemp Clin Trials Commun 2023; 36:101228. [PMID: 38047142 PMCID: PMC10689264 DOI: 10.1016/j.conctc.2023.101228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/24/2023] [Accepted: 11/04/2023] [Indexed: 12/05/2023] Open
Abstract
Background The elderly population is expanding globally. This gives numerous challenges especially regarding hip fracture patients. In the US alone over 300.000 hip fracture patients are treated each year, and a large amount of those develop opoid addiction. Hip fractures require surgical intervention within 24 h and is associated with significant pain even at rest. Postoperative analgesic treatment need to be optimized to ensure adequate pain relief and to prevent subsequent opioid addiction. Previous studies have shown that methadone effectively decreases post-operative opioid consumption but the studies focused on younger patients undergoing elective surgery. This study focus on the use of methadone on the elderly, fragile patients undergoing acute surgery, by first determining the maximal tolerable dose.The hypothesis is the maximal tolerable doses of these hip-fracture patients lies between 0.10 mg/kg and 0.20 mg/kg. This trial aims to estimate the maximum tolerable dose of methadone when administered to elderly patients undergoing surgery for a hip fracture. Method This project is an adaptive dose-finding trial. The continuous reassessment method will estimate the maximum tolerable dose of methadone. The primary outcome will be respiratory depression. The statistical analysis plan will be published a priori to the closure of patient recruitment and statistical analysis of database results. Conclusion The results of this study will give valuable information about the maximally tolerated dose of methadone for postoperative pain relief for elderly patients with hip fractures and potential adverse events.This trial is registered on clinicaltrials.gov with trial registration: NCT05581901. Registered 17 October 2022, https://www.clinicaltrials.gov/ct2/show/NCT05581901?term=methadone&cond = hip&draw = 2&rank = 1.
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Affiliation(s)
- Andreas Kristian Pedersen
- Department of Clinical Research, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
| | - Kevin Heebøll Nygaard
- Department of Clinical Research, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
- Department of Orthopedics, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
| | - Sofie Ronja Petersen
- Department of Clinical Research, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
| | - Kirsten Specht
- Center for COPD, Center for Health and Rehabilitation, Randersgade 60, 2100, København Ø, Denmark
| | - Thomas Strøm
- Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Kresten Philipsens vej 15, 6200, Aabenraa, Denmark
| | - Caroline Margaret Moos
- Department of Clinical Research, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
| | - Helene Skjøt-Arkil
- Department of Clinical Research, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
- Emergency Department, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
| | - Jesper Ougaard Schønnemann
- Department of Orthopedics, University Hospital of Southern Denmark, Kresten Phillipsens vej, Aabenraa, Denmark
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19
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Kharasch ED, Brunt LM, Blood J, Komen H. Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study. Anesthesiology 2023; 139:405-419. [PMID: 37350677 PMCID: PMC10527477 DOI: 10.1097/aln.0000000000004663] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Contemporary perioperative practice seeks to use less intraoperative opioid, diminish postoperative pain and opioid use, and enable less postdischarge opioid prescribing. For inpatient surgery, anesthesia with intraoperative methadone, compared with short-duration opioids, results in less pain, less postoperative opioid use, and greater patient satisfaction. This pilot investigation aimed to determine single-dose intraoperative methadone feasibility for next-day discharge outpatient surgery, determine an optimally analgesic and well-tolerated dose, and explore whether methadone would result in less postoperative opioid use compared with conventional short-duration opioids. METHODS This double-blind, randomized, dose-escalation feasibility and pilot study in next-day discharge surgery compared intraoperative single-dose IV methadone (0.1 then 0.2, 0.25 and 0.3 mg/kg ideal body weight) versus as-needed short-duration opioid (fentanyl, hydromorphone) controls. Perioperative opioid use, pain, and side effects were assessed before discharge. Patients recorded pain, opioid use, and side effects for 30 days postoperatively using take-home diaries. Primary clinical outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30-day opioid consumption, pain, opioid side effects, and leftover opioid counts. RESULTS Median (interquartile range) intraoperative methadone doses were 6 (5 to 7), 11 (10 to 12), 14 (13 to 16), and 18 (15 to 19) mg in 0.1, 0.2, 0.25, and 0.3 mg/kg ideal body weight groups, respectively. Anesthesia with single-dose methadone and propofol or volatile anesthetic was effective. Total in-hospital opioid use (IV milligram morphine equivalents [MME]) was 25 (20 to 37), 20 (13 to 30), 27 (18 to 32), and 25 (20 to 36) mg, respectively, in patients receiving 0.1, 0.2, 0.25 and 0.3 mg/kg methadone, compared to 46 (33 to 59) mg in short-duration opioid controls. Opioid-related side effects were not numerically different. Home pain and opioid use were numerically lower in patients receiving methadone. CONCLUSIONS The most effective and well-tolerated single intraoperative induction dose of methadone for next-day discharge surgery was 0.25 mg/kg ideal body weight (median, 14 mg). Single-dose intraoperative methadone was analgesic and opioid-sparing in next-day discharge outpatient surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
| | - L. Michael Brunt
- Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Jane Blood
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO
| | - Helga Komen
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO
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Friesgaard KD, Brix LD, Kristensen CB, Rian O, Nikolajsen L. Clinical effectiveness and safety of intraoperative methadone in patients undergoing laparoscopic hysterectomy: a randomised, blinded clinical trial. BJA OPEN 2023; 7:100219. [PMID: 37638083 PMCID: PMC10457492 DOI: 10.1016/j.bjao.2023.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/19/2023] [Accepted: 07/12/2023] [Indexed: 08/29/2023]
Abstract
Background Laparoscopic hysterectomy is often carried out as day-stay surgery. Minimising postoperative pain is therefore of utmost importance to ensure timely discharge from hospital. Methadone has several desirable pharmacological features, including a long elimination half-life. Therefore, a single intraoperative dose could provide long-lasting pain relief. Methods Patients scheduled to undergo laparoscopic hysterectomy were randomly allocated to receive methadone (0.2 mg kg-1) or morphine (0.2 mg kg-1) intraoperatively, 60 min before tracheal extubation. Primary outcomes were opioid consumption (oral morphine equivalents in milligrams) at 6 and 24 h. Secondary outcomes included pain intensity at rest and during coughing, patient satisfaction, postoperative nausea and vomiting, and adverse events up to 72 h after completion of surgery. Results The postoperative median opioid consumption was reduced in the methadone group compared with the morphine group at 6 h (35.5 [0-61] mg vs 48 [31-74.5] mg; P=0.01) and 24 h (42 [10-67] mg vs 54.5 [31-83] mg; P=0.03). On arrival at the PACU, pain at rest was significantly lower in patients receiving methadone (numeric rating scale: 3 [2-5] vs 5 [3-6]), whereas pain scores at rest and coughing were not significantly different throughout the rest of the observation period. No differences in other secondary outcomes were found. Conclusions In this randomised, blinded, controlled trial, opioid consumption was reduced during the first 24 postoperative hours in patients receiving methadone without causing an increase in adverse events. The difference observed might be considered as small and of limited clinical relevance. Clinical trial registration NCT03908060; EudraCT no. 2018-004351-20.
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Affiliation(s)
- Kristian D. Friesgaard
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone D. Brix
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
| | | | - Omar Rian
- Department of Anaesthesiology and Intensive Care, Horsens Regional Hospital, Horsens, Denmark
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Nikolajsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Ramírez-Paesano C, Rodiera Clarens C, Sharp Segovia A, Coila Bustinza A, Rodiera Olive J, Juanola Galceran A. Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation. Orphanet J Rare Dis 2023; 18:214. [PMID: 37491286 PMCID: PMC10369693 DOI: 10.1186/s13023-023-02829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.
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Affiliation(s)
- Carlos Ramírez-Paesano
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain.
| | - Claudia Rodiera Clarens
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Allan Sharp Segovia
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Alan Coila Bustinza
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Josep Rodiera Olive
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
| | - Albert Juanola Galceran
- Servei Central d'Anestesiología (Anestalia), Centro Médico Teknon, Grupo Quironsalud, Carrer Vilana 12, 08022, Barcelona, Spain
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22
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Esfahani K, Tennant W, Tsang S, Naik BI, Dunn LK. Comparison of oral versus intravenous methadone on postoperative pain and opioid use after adult spinal deformity surgery: A retrospective, non-inferiority analysis. PLoS One 2023; 18:e0288988. [PMID: 37478144 PMCID: PMC10361497 DOI: 10.1371/journal.pone.0288988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVE To compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery. METHODS This was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3. RESULTS A total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups. CONCLUSIONS Oral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.
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Affiliation(s)
- Kamilla Esfahani
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - William Tennant
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States of America
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23
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D'Souza RS, Esfahani K, Dunn LK. Pro-Con Debate: Role of Methadone in Enhanced Recovery After Surgery Protocols-Superior Analgesic or Harmful Drug? Anesth Analg 2023; 137:76-82. [PMID: 37326866 DOI: 10.1213/ane.0000000000006331] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols are standardized and designed to provide superior analgesia, reduce opioid consumption, improve patient recovery, and reduce hospital length of stay. Yet, moderate-to-severe postsurgical pain continues to afflict over 40% of patients and remains a major priority for anesthesia research. Methadone administration in the perioperative setting may reduce postoperative pain scores and have opioid-sparing effects, which may be beneficial for enhanced recovery. Methadone possesses a multimodal profile consisting of µ-opioid agonism, N-methyl-d-aspartate (NMDA) receptor antagonism, and reuptake inhibition of serotonin and norepinephrine. Furthermore, it may attenuate the development of chronic postsurgical pain. However, caution is advised with perioperative use of methadone in specific high-risk patient populations and surgical settings. Methadone's wide pharmacokinetic variability, opioid-related adverse effects, and potential negative impact on cost-effectiveness may also limit its use in the perioperative setting. In this PRO-CON commentary article, the authors debate whether methadone should be incorporated in ERAS protocols to provide superior analgesia with no increased risks.
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Affiliation(s)
- Ryan S D'Souza
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | | | - Lauren K Dunn
- Departments of Anesthesiology
- Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Affiliation(s)
- Stephanie Pan
- From the Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine, Stanford, California
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Vandse R, Vacaru A, Propp D, Graf J, Sran JK, Pillai P. Retrospective Study of the Safety and Efficacy of Intraoperative Methadone for Pain Management in Patients Undergoing Elective Intracranial Surgery. World Neurosurg 2023; 175:e969-e975. [PMID: 37084845 DOI: 10.1016/j.wneu.2023.04.053] [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: 03/05/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Patients undergoing intracranial surgery experience significant perioperative pain and are typically treated with short-acting opioids. Methadone, with its prolonged half-life and multimodal central nervous system effects, presents a promising option for managing postcraniotomy pain. Despite its proven efficacy in other types of surgeries, the use of methadone in patients undergoing craniotomy has not yet been explored. METHODS A retrospective chart review was conducted for 60 adult patients ranging in age from 18 to 81 years who received methadone during intracranial surgeries. The primary outcome of interest was the total opioid consumption in oral morphine milligram equivalents (MMEs) and patient-reported pain scores within 24 hours and up to 72 hours postoperatively. RESULTS The methadone dosage varied from 5 to 20 mg. In the infratentorial group, the median total MME on postoperative day 1, 2, and 3 was 30.5, 17, and 0.8, respectively, with mean pain scores of 3.56, 3.91, and 2.71. In the supratentorial group, the median total MME on postoperative day 1, 2, and 3 was 17.85, 15.4, and 1.2, with mean pain scores of 2.31, 1.68, and 2.21, respectively. Patients who were chronic opioid users had significantly higher pain scores and average opioid use (P < 0.05). None of the patients required administration of naloxone or airway interventions. Comparison with the historical control showed that our study patients had lower pain scores and MME. CONCLUSIONS The single intraoperative dose of methadone is well tolerated by adult patients undergoing various types of intracranial surgeries, with minimal side effects, including elderly patients aged 65 years or older.
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Affiliation(s)
- Rashmi Vandse
- Loma Linda University Medical Center, Department of Anesthesiology, Loma Linda, California, USA.
| | - Alexandra Vacaru
- Loma Linda University Medical Center, Department of Anesthesiology, Loma Linda, California, USA
| | - Dennis Propp
- Loma Linda University Medical Center, Department of Anesthesiology, Loma Linda, California, USA
| | - Justin Graf
- Loma Linda University Medical Center, Department of Anesthesiology, Loma Linda, California, USA
| | - Jasmine K Sran
- Loma Linda University Medical Center, Department of Anesthesiology, Loma Linda, California, USA
| | - Promod Pillai
- Loma Linda University Medical Center, Department of Neurosurgery, Loma Linda, California, USA
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Mercadante S. Intravenous Methadone for Perioperative and Chronic Cancer Pain: A Review of the Literature. Drugs 2023:10.1007/s40265-023-01876-7. [PMID: 37308798 DOI: 10.1007/s40265-023-01876-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/14/2023]
Abstract
Intravenous methadone may be useful in acute and chronic pain management compared with other opioids because of its pharmacokinetic and pharmacodynamic characteristics, including the long duration of effect and ability to modulate both pain stimuli propagation and analgesic descending pathways. However, methadone is underused in pain medicine because of several misperceptions. A review of studies was performed to assess data regarding the use of methadone in perioperative pain and chronic cancer pain. The majority of studies have shown that intravenous methadone produces an effective postoperative analgesia and lowers opioid consumption in the postoperative period, without more adverse effects in comparison with other opioid analgesics, and has an interesting potential to prevent persistent postoperative pain. A minority of studies investigated the use of intravenous methadone for cancer pain management. These studies were mostly case series that showed promising activities of intravenous methadone for difficult pain conditions. There is sufficient evidence suggesting that intravenous methadone is effective in perioperative pain, while more studies are needed in patients with cancer pain.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
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27
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Stone AB, Hughes AP, Soffin EM. Intraoperative Methadone and Short Stay Spine Surgery: Possible Barriers to Implementation and Future Opportunities. J Pain Res 2022; 15:2657-2662. [PMID: 36091623 PMCID: PMC9462933 DOI: 10.2147/jpr.s367940] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
The frequency of shorter stay spine surgery is increasing. Acute pain is a common barrier to discharge following spine surgery. Long-acting opioid medications like methadone have the potential to provide sustained analgesia when given intraoperatively. Methadone has been effectively used in complex spine surgery, cardiac surgery, and more recently applied to ambulatory procedures. In this article, we summarize the pertinent available literature on the use of intraoperative methadone for spine surgery as well as the recent data on intraoperative methadone for ambulatory surgery. The aim of this perspectives article is to describe the potential opportunities for applying intraoperative methadone to shorter stay spine surgery as well as barriers to more widespread use. While there are currently no trials that have specifically studied methadone for shorter stay spine surgery specifically to date, it is a promising area for future research.
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Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
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Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr Anaesth 2022; 32:982-992. [PMID: 35751474 DOI: 10.1111/pan.14514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 11/28/2022]
Abstract
Providing effective acute pain management to hospitalized children can help improve outcomes, decrease length of stay, and increase patient and parental satisfaction. Error traps (circumstances that lead to erroneous actions or undesirable consequences) can result in inadequately controlled pain, unnecessary side effects, and adverse events. This article highlights five error traps encountered when managing acute pain in children. They include failure to appropriately assess pain, optimally utilize regional anesthesia, select suitable systemic analgesics, identify and treat medication-related side effects, and consider patient characteristics when choosing medication or dosing route. These issues are easily addressed when the clinician is cognizant of ways to anticipate, identify, and mitigate or avoid these errors.
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Affiliation(s)
- Tricia M Vecchione
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California, USA
| | - Constance L Monitto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Carullo V, Morrone K, Weiss M, Choi J, Gao Q, Pisharoty S, Moody K, Manwani D. Demand-only patient-controlled analgesia for treatment of acute vaso-occlusive pain in sickle cell disease. Pediatr Blood Cancer 2022; 69:e29665. [PMID: 35294090 DOI: 10.1002/pbc.29665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 02/04/2022] [Accepted: 02/27/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is a chronic illness that is associated with frequent admissions for vaso-occlusive episodes (VOE). Opioids are frequently utilized in pain management, but dosing is often provider dependent. Opioids cause both short-term and long-term side effects, so the minimal effective dose is desired. This study examined demand-only patient-controlled analgesia (PCA) in pediatric patients. METHODS A new clinical practice guideline (CPG) for a single institution was implemented, which eliminated basal infusion dosing for PCAs on hospital admission. The primary aim of this retrospective study was to evaluate length of stay (LOS) before and after implementation of a CPG of demand-only PCA and, in a selected subpopulation, addition of short-term methadone. Secondary aims included opioid utilization, acute chest syndrome (ACS), and hypoxia. Inclusion criteria included SCD, ≤21 years of age, uncomplicated VOE admission, and ≥ 3 and ≤ 8 hospital admissions for SCD pain control within one calendar year. RESULTS LOS decreased postintervention (7.2 ± 5.1 vs 4.5 ± 3.8 days, P < 0.001). Mean total opioid utilization in morphine equivalents mg/kg markedly decreased between the cohorts (13.3 ± 33.8 vs 3.6 ± 3.0, P < 0.001). ACS (21.9% vs 2.8%, P = 0.004) and hypoxia (28% vs 6.9%, P< 0.001) decreased significantly as well. CONCLUSION Bolus PCA dosing of opioids resulted in decreased LOS and reductions in opioid utilization, hypoxia, and ACS.
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Affiliation(s)
- Veronica Carullo
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Kerry Morrone
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Meagan Weiss
- Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Jaeun Choi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Qi Gao
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Shantanu Pisharoty
- Department of Nephrology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Karen Moody
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deepa Manwani
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Sherazee EA, Chen SA, Li D, Li D, Frank P, Kiaii B. Pain Management Strategies for Minimally Invasive Cardiothoracic Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:167-176. [PMID: 35521910 DOI: 10.1177/15569845221091779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Elan A Sherazee
- Department of Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Sarah A Chen
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Pharmacy Services, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Paul Frank
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Bob Kiaii
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
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31
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Shlobin NA, Rosenow JM. Nonopioid Postoperative Pain Management in Neurosurgery. Neurosurg Clin N Am 2022; 33:261-273. [DOI: 10.1016/j.nec.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lai G, Aroke EN, Zhang SJ. Rediscovery of Methadone to Improve Outcomes in Pain Management. J Perianesth Nurs 2022; 37:425-434. [PMID: 35396188 DOI: 10.1016/j.jopan.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022]
Abstract
Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent μ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.
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Affiliation(s)
- Gloria Lai
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
| | - Edwin N Aroke
- Nurse Anesthesia Program, School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah Jingying Zhang
- Nurse Anesthesiology Program, School of Nursing, University of South Florida, Tampa, CA; Nurse Anesthesia Program, School of Nursing, Samuel Merritt University, Oakland, CA.
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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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Edinoff AN, Kaplan LA, Khan S, Petersen M, Sauce E, Causey CD, Cornett EM, Imani F, Moradi Moghadam O, Kaye AM, Kaye AD. Full Opioid Agonists and Tramadol: Pharmacological and Clinical Considerations. Anesth Pain Med 2021; 11:e119156. [PMID: 34692448 PMCID: PMC8520671 DOI: 10.5812/aapm.119156] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 12/22/2022] Open
Abstract
Opioids are mu receptor agonists and have been an important part of pain treatment for thousands of years. In order to use these drugs appropriately and successfully in patients, whether to control pain, to treat opiate-induced side effects, or opiate withdrawal syndromes, a solid understanding of the pharmacology of such drugs is crucial. The most recognized full agonist opioids are heroin, morphine, codeine, oxycodone, meperidine, and fentanyl. Phenanthrenes refer to a naturally occurring plant-based compound that includes three or more fused rings. The opioids derived from the opium plant are phenanthrene derivatives, whereas most synthetic opioids are simpler molecules that do not have multiple rings. Methadone acts as a synthetic opioid analgesic similar to morphine in both quality and quantity; however, methadone lasts longer and in oral form, has higher efficacy, and is considered a diphenylheptane. Fentanyl is a strong synthetic phenylpiperdine derivative that exhibits activity as a mu-selective opioid agonist approximately 50 to 100 times more potent than morphine. Meperidine is another medication which is a phenylpiperdine. Tramadol is considered a mixed-mechanism opioid drug, as it is a centrally acting analgesic that exerts its effects via binding mu receptors and blocking the reuptake of monoamines. Some of the most common adverse effects shared among all opioids are nausea, vomiting, pruritus, addiction, respiratory depression, constipation, sphincter of Oddi spasm, and miosis (except in the case of meperidine). Chronic opioid usage has also established a relationship to opioid-induced hypogonadism and adrenal suppression. Physicians must be stewards of opioid use and use opioids only when necessary.
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Affiliation(s)
- Amber N. Edinoff
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Leah A. Kaplan
- Louisiana State University Shreveport, School of Medicine, Shreveport, LA, USA
| | - Sami Khan
- American University of the Caribbean, School of Medicine, USA
| | - Murray Petersen
- Louisiana State University Health Science Center Shreveport, Department of Psychiatry and Behavioral Medicine, Shreveport, LA, USA
| | - Emily Sauce
- Louisiana State University New Orleans, School of Medicine, New Orleans, LA, USA
| | | | - Elyse M. Cornett
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Moradi Moghadam
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA, USA
| | - Alan D. Kaye
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA
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Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes. Braz J Anesthesiol 2021; 72:560-566. [PMID: 34216703 PMCID: PMC9515670 DOI: 10.1016/j.bjane.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/23/2021] [Accepted: 06/12/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03–0.28]), and (P2) (PR = 0.42%; 95% CI [0.20–0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20–29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22–8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p < 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p < 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.
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Effect of intraoperative methadone vs other opioids on postoperative outcomes: a meta-analysis of randomized controlled studies. Pain 2021; 163:e153-e164. [PMID: 34108437 DOI: 10.1097/j.pain.0000000000002296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
ABSTRACT Recent randomized controlled trials comparing the efficacy between intraoperative methadone and other opioids on postoperative outcomes have been limited by their small sample sizes and conflicting results. We performed a meta-analysis on randomized controlled trials which investigated outcomes between methadone and an opioid control group. Primary outcome data included postoperative opioid consumption, number of patients who received postoperative opioids, time to first analgesic, and pain scores. Secondary outcomes included time to extubation and incidence of nausea, vomiting, and respiratory depression. Statistical analysis was performed using RevMan. A P < 0.05 was considered statistically significant. Nine studies comprising 632 patients were included. There was no statistically significant reduction in opioid consumption postoperatively between the groups. Forty-seven percentage of patients in the methadone group received a dose of opioid postoperatively compared with 55% in the other opioids control group, which was not statistically significant. (P = 0.25) There was no difference in average time to receiving first postoperative analgesic among the groups. Pain scores within 24 hours were significantly lower in the methadone group when compared with other opioids (8 studies, n = 622, -0.49 [-0.74, -0.23], P = 0.002). However, there was no difference between 24 and 72 hours. There was no difference among the groups with respect to extubation time, nausea, vomiting, or respiratory depression. This meta-analysis concludes that there is currently insufficient evidence for the use of intraoperative methadone, when compared with other opioids. Although there was a decrease in average pain scores with methadone when compared with controls at 24 hours, there was no difference between 24 and 72 hours.
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37
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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia. Pain Manag 2021; 11:405-417. [PMID: 33779215 DOI: 10.2217/pmt-2020-0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.
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Affiliation(s)
- Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kevin M Hellman
- Department of Obstetrics & Gynecology, NorthShore University Health System & Pritzker School of Medicine at the University of Chicago, Evanston, IL 60201, USA
| | - Dominika James
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Adam C Adler
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology & Perioperative Pain Medicine, Texas Children's Hospital, Houston, TX 77030, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Sadhasivam S, Aruldhas BW, Packiasabapathy S, Overholser BR, Zhang P, Zang Y, Renschler JS, Fitzgerald RE, Quinney SK. A Novel Perioperative Multidose Methadone-Based Multimodal Analgesic Strategy in Children Achieved Safe and Low Analgesic Blood Methadone Levels Enabling Opioid-Sparing Sustained Analgesia With Minimal Adverse Effects. Anesth Analg 2021; 133:327-337. [PMID: 33481403 DOI: 10.1213/ane.0000000000005366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intraoperative methadone, a long-acting opioid, is increasingly used for postoperative analgesia, although the optimal methadone dosing strategy in children is still unknown. The use of a single large dose of intraoperative methadone is controversial due to inconsistent reductions in total opioid use in children and adverse effects. We recently demonstrated that small, repeated doses of methadone intraoperatively and postoperatively provided sustained analgesia and reduced opioid use without respiratory depression. The aim of this study was to characterize pharmacokinetics, efficacy, and safety of a multiple small-dose methadone strategy. METHODS Adolescents undergoing posterior spinal fusion (PSF) for idiopathic scoliosis or pectus excavatum (PE) repair received methadone intraoperatively (0.1 mg/kg, maximum 5 mg) and postoperatively every 12 hours for 3-5 doses in a multimodal analgesic protocol. Blood samples were collected up to 72 hours postoperatively and analyzed for R-methadone and S-methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidene (EDDP) metabolites, and alpha-1 acid glycoprotein (AAG), the primary methadone-binding protein. Peak and trough concentrations of enantiomers, total methadone, and AAG levels were correlated with clinical outcomes including pain scores, postoperative nausea and vomiting (PONV), respiratory depression, and QT interval prolongation. RESULTS The study population included 38 children (10.8-17.9 years): 25 PSF and 13 PE patients. Median total methadone peak plasma concentration was 24.7 (interquartile range [IQR], 19.2-40.8) ng/mL and the median trough was 4.09 (IQR, 2.74-6.4) ng/mL. AAG concentration almost doubled at 48 hours after surgery (median = 193.9, IQR = 86.3-279.5 µg/mL) from intraoperative levels (median = 87.4, IQR = 70.6-115.8 µg/mL; P < .001), and change of AAG from intraoperative period to 48 hours postoperatively correlated with R-EDDP (P < .001) levels, S-EDDP (P < .001) levels, and pain scores (P = .008). Median opioid usage was minimal, 0.66 (IQR, 0.59-0.75) mg/kg morphine equivalents/d. No respiratory depression (95% Wilson binomial confidence, 0-0.09) or clinically significant QT prolongation (median = 9, IQR = -10 to 28 milliseconds) occurred. PONV occurred in 12 patients and was correlated with morphine equivalent dose (P = .005). CONCLUSIONS Novel multiple small perioperative methadone doses resulted in safe and lower blood methadone levels, <100 ng/mL, a threshold previously associated with respiratory depression. This methadone dosing in a multimodal regimen resulted in lower blood methadone analgesia concentrations than the historically described minimum analgesic concentrations of methadone from an era before multimodal postoperative analgesia without postoperative respiratory depression and prolonged corrected QT (QTc). Larger studies are needed to further study the safety and efficacy of this methadone dosing strategy.
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Affiliation(s)
| | - Blessed W Aruldhas
- From the Department of Anesthesia.,Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | | | - Brian R Overholser
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, Indiana
| | | | | | | | - Ryan E Fitzgerald
- Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery
| | - Sara K Quinney
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Obstetrics and Gynecology.,Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana
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The analgesic effect of intravenous lidocaine versus intrawound or epidural bupivacaine for postoperative opioid reduction in spine surgery: A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 201:106438. [PMID: 33385933 DOI: 10.1016/j.clineuro.2020.106438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/26/2020] [Accepted: 12/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pain management following spine surgery remains a challenge. The significant use of opioids may lead to opioid-related adverse events. These complications can increase perioperative morbidity and rapidly expend health care resources by developing chronic pain. Although intraoperative pain control for surgery has been studied in the literature, a thorough assessment of the effect in spine surgery is rarely reported. The objective of the present study was to examine the outcomes of intraoperative intravenous lidocaine and intrawound or epidural bupivacaine use in spine surgery. METHODS An electronic literature search was conducted for studies on the use of lidocaine and bupivacaine in spine surgery for all years available. Only articles in English language were included. Postoperative opioid consumption, VAS score, nausea/vomiting, and length of hospital stay comprised the outcomes of interest. Pooled descriptive statistics with Risk Ratios (RR), Mean Differences (MD) and 95 % confidence interval were used to synthesize the outcomes for each medication. RESULTS A total of 10 studies (n = 579) were included in the analysis. Comparison of the opioid consumption revealed a significant mean difference between lidocaine and bupivacaine (MD: -12.25, and MD: -0.4, respectively, p = 0.01), favoring lidocaine. With regard to postoperative VAS, the pooled effect of both groups decreased postoperative pain (MD: -0.61 (95 % CI: -1.14, -0.08)), with a more significant effect in the lidocaine group (MD: -0.84, (95 % CI: -1.21, -0.48)). There was no significant effect in length of stay, and postoperative nausea/vomiting. CONCLUSIONS The results of the present meta-analysis indicate that lidocaine and bupivacaine use may decrease postoperative pain and opioid consumption. Lidocaine had a stronger effect on the reduction of opioid consumption compared to bupivacaine.
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Lönnqvist PA. What has happened since the First World Congress on Pediatric Pain in 1988? The past, the present and the future. Minerva Anestesiol 2020; 86:1205-1213. [DOI: 10.23736/s0375-9393.20.14391-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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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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Pontes JPJ, Braz FR, Módolo NSP, Mattar LA, Sousa JAG, Navarro E Lima LH. Intra-operative methadone effect on quality of recovery compared with morphine following laparoscopic gastroplasty: a randomised controlled trial. Anaesthesia 2020; 76:199-208. [PMID: 32803791 DOI: 10.1111/anae.15173] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 01/18/2023]
Abstract
The effect of intra-operative intravenous methadone on quality of postoperative recovery was compared with morphine after laparoscopic gastroplasty. We included 137 adult patients with a body mass index > 35 kg.m-2 who underwent bariatric surgery. Patients were allocated at random to receive either intra-operative methadone (n = 69) or morphine (n = 68). All patients received the same postoperative care and analgesia. The primary outcome of postoperative quality of recovery was assessed using the Quality of Recovery-40 questionnaire total score 24 h after surgery. Secondary outcomes were assessed in the post-anaesthesia care unit the night of the day of surgery (T1), in the morning after surgery (T2); and at night on the day following surgery (T3). The median (IQR [range]) total Quality of Recovery-40 questionnaire score of 194 (190-197 [165-200]) was higher (p < 0.0001) in the methadone group compared with the score of 181 (174-185.5 [121-200]) in the morphine group. In the post-anaesthesia care unit, the pain burden; incidence of nausea and vomiting; rescue morphine dose; and time to discharge, were significantly lower in the methadone group. On the ward, the methadone group had a lower: incidence of rescue morphine requests at T1 (5.8 vs. 54.4%, p < 0.0001) and T2 (0 vs. 20.1%, p < 0.0001); and incidence of nausea (21.7 vs. 41.2%, p = 0.014), compared with the morphine group. We conclude that intra-operative intravenous methadone improved quality of recovery in patients who underwent laparoscopic gastroplasty, compared with intra-operative morphine. Methadone also reduced postoperative pain, postoperative opioid consumption and the incidence of opioid-related adverse events.
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Affiliation(s)
- J P J Pontes
- Department of Anaesthesiology, Santa Genoveva Hospital Complex, Uberlândia, Minas Gerais, Brazil.,Department of Anaesthesiology, Santa Genoveva Hospital Complex, Uberlândia, Minas Gerais, Brazil
| | - F R Braz
- Department of Anaesthesiology, Santa Genoveva Hospital Complex, Uberlândia, Minas Gerais, Brazil
| | - N S P Módolo
- Botucatu School of Medicine, UNESP, São Paulo, Brazil
| | - L A Mattar
- Department of Surgery, Santa Genoveva Hospital Complex, Uberlândia, Minas Gerais, Brazil
| | - J A G Sousa
- Department of Surgery, Santa Genoveva Hospital Complex, Uberlândia, Minas Gerais, Brazil
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Wolfe RC. Intraoperative Methadone: New Use for an Old Drug. J Perianesth Nurs 2020; 35:219-221. [PMID: 32247434 DOI: 10.1016/j.jopan.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Rachel C Wolfe
- Pharmacy Department, Barnes-Jewish Hospital, St. Louis, MO.
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The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials. Anesthesiol Res Pract 2020; 2020:6974321. [PMID: 32280341 PMCID: PMC7140144 DOI: 10.1155/2020/6974321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 12/28/2022] Open
Abstract
Methods We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool. Results Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of −0.51 (−1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of −1.11 (−1.88 to −0.33), P=0.005, and at 24 hours, WMD (95% CI) of −1.35 (−2.03 to −0.67), P < 0.001. Conclusions The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.
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