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.
OVERALL: A variety of doses have been used in clinical trials, ranging from 0.1 to 0.3 mg/kg, with the majority of studies using a dose of either 0.2 mg/kg or a fixed dose of 20 mg.
Cardiac: Ketamine current pt weight (non-adjusted) 0.2mg/kg/hr start after induction (after lines placed) + 0.35 mg/kg 5-10 minutes prior to incison. Change from 0.2mg/kg/hr to 0.1mg/kg/hr when rewarming. Infusion off when driving sternal wires. Methadone currently not available.
Non-cardiac (cases 2+ hours duration) Ketamine: 0.3mg/kg (non-adjusted, current weight) at induction. Methadone currently not available.
Outpatient: ketamine not currently available for use.
July 2020
Cardiac: Ketamine IBW 0.3mg/kg total: 0.2mg/kg prior to incision + 0.1mg/kg when separate from CPB
0.2 mg/kg of methadone (based on ideal body weight, up to a maximal dose of 20 mg)
250 mg of ketamine was added to the dextrose 5% in water bag (total volume 500 ml). 500 ml bags were connected to a pump that was programed to deliver an infusion of ketamine dosed at ideal body weight (or an equal volume of dextrose 5% in water) at a rate of 0.3 mg · kg−1 · h−1 from induction of anesthesia until surgical closure, at which time the infusion was decreased to 0.1 mg · kg−1 · h−1. The infusion was maintained at a rate of 0.1 mg · kg−1 · h−1 in the postanesthesia care unit (PACU) and for the next 48 postoperative hours. Dosing of ketamine was based on recommendations in the literature17,18 and from clinical experience at our institution.
The experience is one I’ll truly cherish. I’ll have to go at least yearly. These people need so much and it’s really an honor to be able to reach out to them. Had 3 cases today. All pedi burns..6y, 14y, 6y. First case, the 6y old was so brave. We did a right axillary contracture release with skin graft lasted about 2h. 2nd case was the toughest anesthetically. She had burns to her face and had a mouth opening of barely 2 of my fingers. I barely got a 2.5 Lma thru. They released contractures on her neck and eyelids. She coughed in the middle of the case as one of surgeons was putting stitch in neck. She laryngospasmed….oy! Sat went down to 70s…had to give prop to break it. That, I could’ve lived without. Last case was a screaming, crying 6y. Had to tackle mask him down…luckily, he went down nicely. They did a left hand/thumb release. All the pts did well in the pacu. 🙂 so far so good…. now for dinner, drinks, and hanging with the group.
I´m currently in Antigua. ´It´s a cute, beautiful city that used to be the ancient capitol of Guatemala. We´ve walked around the city, which reminded me of San Juan, Puerto Rico. Cute city blocks with very colorful buildings. The people are extremely friendly. Heading out to a Spanish class at 1:30p for a refresher. My Project HANDS family is very nice, helpful and I can definitely see this trip being a great one! More to follow…
Back in December, I found a group on the internet called Project Hands. It’s a Vancouver based group who puts together a healthcare team composed of doctors, nurses, techs, administrators, and engineers to send over to Guatemala to deliver surgical care. I’m part of the May 2011 team. I’ve never done a medical mission trip, but I think they’re important to see how others live life and deal with medical problems. I love experiencing new cultures! Today, I leave for Guatemala and am quite excited to get going on the trip. Now, as an anesthesiologist, I wonder about the equipment and drugs that I’ll have access to…. will they be the same one I’m familiar with or will they be some kind of rigged contraption with an O2 flow tubing hooked up to volatile agent? I’ll try to post daily and include some pics as well. I’m supposed to arrive in Guatemala tonight….
Pediatric cardiac anesthesiologists are pretty much the Gods of anesthesia. What do I mean by this? Well, putting kids to sleep and finding IVs and managing their little airways can be tricky. Now, let’s take that and make it more complex by giving them funky heart anatomy and connections and we’ve got some real tricky anesthesia!
Picture tiny babies, 1-2kg (for the U.S.: 2-4lbs), with teeny tiny hearts…who only have a fightin’ chance in this world with corrective heart surgery. These tiny hearts are beating away…with some type of pathology that will kill them oftentimes before they reach adulthood.
Sick kids + general anesthesia = possible scary scenario. Throw in a really good pediatric cardiac anesthesiologist (and pedi heart surgeon)… and that could mean many more years of happy memories! I’m not sure how these amazing physicians sleep at night (high stress!), but they’re outstanding and certainly have earned my respect!
Some of the pathology I’ve seen: Tetralogy of Fallot, hypoplastic left heart syndrome, coarctation, bicuspid aortic valve, mitral valve prolapse, tricuspid valve prolapse, heterotaxy, unbalanced AV canal, complete vascular ring, patients who were s/p Norwood-Sano, double outlet RV
All I can say is that rotating through pedi hearts for a month was an outstanding experience… one that all adult cardiac anesthesiologists should do.
Pediatric cardiac anesthesiologists are pretty much the Gods of anesthesia. What do I mean by this? Well, putting kids to sleep and finding IVs and managing their little airways can be tricky. Now, let’s take that and make it more complex by giving them funky heart anatomy and connections and we’ve got some real tricky anesthesia!
Picture tiny babies, 1-2kg (for the U.S.: 2-4lbs), with teeny tiny hearts…who only have a fightin’ chance in this world with corrective heart surgery. These tiny hearts are beating away…with some type of pathology that will kill them oftentimes before they reach adulthood.
Sick kids + general anesthesia = possible scary scenario. Throw in a really good pediatric cardiac anesthesiologist (and pedi heart surgeon)… and that could mean many more years of happy memories! I’m not sure how these amazing physicians sleep at night (high stress!), but they’re outstanding and certainly have earned my respect!
Some of the pathology I’ve seen: Tetralogy of Fallot, hypoplastic left heart syndrome, coarctation, bicuspid aortic valve, mitral valve prolapse, tricuspid valve prolapse, heterotaxy, unbalanced AV canal, complete vascular ring, patients who were s/p Norwood-Sano, double outlet RV
All I can say is that rotating through pedi hearts for a month was an outstanding experience… one that all adult cardiac anesthesiologists should do.
Sleepy Time 