Methadone for perioperative pain #methadone #pain #ERAS
There’s a lot of great data that methadone use decreases postoperative narcotics use in cardiac surgery patients, and I believe it would really be a beneficial drug in an ERAS pathway for early extubation, decreased LOS in ICU and hospital, and better patient satisfaction. Please see the articles below/attached for references.
I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!
The Food and Drug Administration approved alvimopan in 2008 as an oral, peripherally acting opioid μ-receptor antagonist to accelerate GI recovery in patients undergoing bowel resection.87,88 A pooled analysis of 3 prospective randomized trials demonstrated that a 12 mg dosing regimen provided optimal reduction in GI morbidity and return of GI function after abdominal surgery.89
Vaughan-Shaw et al90 performed a meta-analysis involving 3 studies of 1388 patients undergoing open abdominal surgery (bowel resection and hysterectomy) within a defined accelerated recovery program. This study demonstrated a 16- to 20-hour reduction in the time to GI recovery and discharge order associated with alvimopan use. It is important to note that the defined accelerated recovery program in each of these studies was limited to early removal of prophylactic NG tubes, clear liquids on POD 1, and encouragement of ambulation. Each study utilized patient-controlled analgesia with heavy doses of opioids.91 Therefore, these trials were conducted in open surgery within the setting of an opioid-centric treatment pathway, which is not consistent with most modern day ERPs. There are no high-quality prospective randomized trials examining the efficacy of alvimopan within the setting of an opioid-restricted modern day ERP or after minimally invasive surgery.
However, there are large database studies evaluating the use of alvimopan in current practice. The Michigan Surgical Quality Collaborative group reported that the usage of alvimopan in the community resulted in a decrease in mean LOS (4.8 vs 6.4 days) due principally to a reduction in ileus (7.9% vs 2.3%).92 Similarly, the Surgical Care and Outcomes Assessment Program evaluated 14,781 patients undergoing elective CRS comparing those that did (11%) and did not receive (89%) alvimopan and found a LOS reduction of 1.8 days and a cost reduction of $2017 related to ileus reduction in patients receiving alvimopan.93 Adam et al94 reported on a single institution experience of 660 patients after implementation of alvimopan as part of an established ERP (197 alvimopan; 463 no alvimopan) and demonstrated a faster return of bowel function, a lower incidence of ileus, a shorter LOS, and a hospital cost savings of $1492 per patient. These results are consistent with similar retrospective cohort study by Itawi et al.95 It should be noted that the potential benefits of alvimopan are likely related to the amount/duration of opioid analgesics as demonstrated by 2 separate retrospective studies demonstrating minimal benefit in a laparoscopic colectomy population managed with minimal opioids.96,97
The data suggest a reproducible benefit associated with the use of alvimopan in open CRS; however, the cost/benefit ratio must be considered within the context of the opioid administration of each institution’s ERP. Barletta et al50 confirmed that the intravenous opioid dosage that results in ileus might be quite modest (2-mg hydromorphone). Additional data would be helpful to clearly define the minimum dose exposure and route of administration of opioids that would best guide the use of alvimopan within a comprehensive ERP. However, if modest opioid exposure is anticipated, the agent appears to be cost-effective.
I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.
This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.
Ketamine: (different doses I’ve seen in the literature below)
• Induction: 0.2-0.5 mg/kg
• Infusion: 0.1mg/kg/hr before incision
◦ 2mcg/kg/hr x 24hr (spine)
◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)
Overall, moderate evidence supports use of subanesthetic IV ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids for perioperative analgesia (grade B recommendation, moder- ate level of certainty).
What I’m using nowadays:
Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved. Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol. Patients are more comfortable and require less pain medication.
Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming.
Cardiac open hearts: induction infusion 0.3mg/kg/hr + 0.5mg/kg right before incision. 0.2mg/kg/hr when commence CPB. 0.1mg/kg/hr when re-warming. Stop infusion when driving wires.
Main OR: induction 0.35mg/kg + 0.2mg/kg/hr or 3mcg/kg/min = extubate patient in OR. Stop infusion when closing.
Question 1: Which patients and acute pain conditions should be considered for ketamine treatment? Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain? Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia? Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings? Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
Question 5: What is the evidence to support nonparenteral ketamine for acute pain management? Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain? Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.