Original Article|Articles in Press

A Single-Center Retrospective Comparison of Opioid Based and Multimodal Analgesic Regimens in Adult Cardiac Surgery

Published:March 09, 2023DOI:


      • A multimodal regimen including methadone and dexmedetomidine was associated with the largest reduction in pain scores and opioid consumption
      • Opioid use immediately prior to discharge was reduced to a median of zero oral morphine equivalents with the methadone and dexmedetomidine multimodal regimen



      This retrospective study was performed to compare outcomes of two different multimodal analgesic regimens with an opioid-based regimen.


      Two-stage, retrospective study.


      Large, tertiary care facility.


      Adult cardiac surgical patients.


      Patients received one of three regimens, opioid only and two multimodal regiments. The opioid regimen included intraoperative fentanyl and patient-controlled analgesia pumps. Multimodal regimen one included preoperative extended-release oxycodone, intraoperative ketamine infusion, and postoperative morphine suppository. Multimodal regimen two included intraoperative methadone and dexmedetomidine infusion.

      Measurement and Main Results

      Outcomes measured included opioid use, pain scores, time to tracheal extubation, postoperative antiemetic use as a surrogate marker for postoperative nausea and vomiting (PONV), age, sex, surgical procedure(s), body mass index (BMI), time to first bowel movement, ICU LOS, and hospital LOS Intraoperative median oral morphine equivalents (OME) declined from 425 mg (314, 518) to 150 mg (75, 150) and 230 mg (160, 240), p<0.001, in multimodal regimens one and two, respectively, compared with the opioid only regimen. Pre-discharge opioid use was reduced from a median OME of 7.5 mg (0, 22.5) to 5 mg (0, 22.5) and 0 mg (0, 15.0), p<0.001, in multimodal regimens one and two, respectively. Pain scores were reduced in the multimodal regimen 2 for hours 0-6 (estimated difference = -1.5, 95% CI -1.8 to -1.2, p<0.001) compared with the opioid only regimen. PONV treatment was reduced in multimodal regimen 1 versus the opioid based or multimodal regimen 2 (53% versus 64% and 62%) and time to tracheal extubation was clinically equivalent across all regimens, 4.2 (2.8, 6.0), 3.6 (2.3, 5.7), and (3.0, 6.2) hours for the opioid and multimodal regimens one and two, respectively.


      Multimodal analgesic regimens, particularly when incorporating methadone and dexmedetomidine, corresponded to a significant reduction in total and pre-discharge opioid use in cardiac surgical patients.

      Graphical abstract


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