Highlights
- •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
Abstract
Objectives
This retrospective study was performed to compare outcomes of two different multimodal
analgesic regimens with an opioid-based regimen.
Design
Two-stage, retrospective study.
Setting
Large, tertiary care facility.
Participants
Adult cardiac surgical patients.
Interventions
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.
Conclusions
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
Graphical Abstract
Keywords
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Article info
Publication history
Publication stage
In Press Accepted ManuscriptFootnotes
Disclosure Statement: E.D. Wittwer: Consultant for Pacira Biosciences, Inc. The remaining authors report no disclosures or conflicts of interest.
Financial disclosure: This project was funded by a Mayo Clinic Department of Anesthesiology Small Grant Award.
IRB approval: Study was approved by the IRB on 4/30/20, IRB number 17-004249.
Acknowledgements
Korey K. Springman, MD: This contributor helped institute the first multimodal regimen.
Nathan J. Brinkman, PharmD, RPh; Mayo Clinic; Rochester, MN: This contributor helped design and implement the intraoperative components of the multimodal regimens.
Christopher J. Arendt, PharmD, RPh; Mayo Clinic College of Medicine; Rochester, MN: This contributor helped design and implement the postoperative components of the multimodal regimens.
Janelle O. Poyant, PharmD: This contributor helped implement the first multimodal regimen.
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