Methadone for ERAS Spine Cases

[gasman19]

Do any of your institutions have methadone infusions as part of ERAS or general protocols for spine cases? Would be interested in hearing others' experiences with this.

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[MirrorTodd]

Do any of your institutions have methadone infusions as part of ERAS or general protocols for spine cases? Would be interested in hearing others' experiences with this.

No infusions that I know of. Typically a bolus up front.

 

[triggermaster]

Do any of your institutions have methadone infusions as part of ERAS or general protocols for spine cases? Would be interested in hearing others' experiences with this.

Why would you ever infuse such a long lasting drug?

 

[APA 32]

Do any of your institutions have methadone infusions as part of ERAS or general protocols for spine cases? Would be interested in hearing others' experiences with this.

just methadone bolus with induction

 

[MirrorTodd]

Why would you ever infuse such a long lasting drug?

Take advantage of that context sensitive half-time bro!

 

[IlDestriero]

We use a bolus on induction for pediatric scoliosis cases.

 

[JeffGarrett]

Bolus was all i did. typically 0.1mg/kg. never exceeded 10 mg.

 

[Beeftenderloin]

Single 0.3mg/kg bolus up front. This dosing is supported by literature (Murphy et al.) for reduciing pain after spine surgery out to 90 days post-op. Occasionally I go down to 0.2mg/kg if they're more frail appearing. Infusion sounds kinda bonkers for a drug with a 24hr half-life.

 

[jwk]

We use it mainly on longer spine cases with chronic pain patients that are already taking lots of narcs at home. Typically 10mg of methadone at the start and far less narcotic requirement for the rest of the case.

 

[PpfSuxTube]

Take advantage of that context sensitive half-time bro!

Hmm? What does context sensitive half time have to do with an upfront bolus?

 

[IDGARA]

I give between 0.1 - 0.25 mg/kg IBW at induction, never part of a protocol.
I do this for all kinds of cases, not just spines.

 

[Blockit]

I use a good sized oral dose in preop for complex spine surgery (multilevel with hardware, redo, etc). As was stated earlier this practice is supported in the literature.

 

[SRYSPAC]

We use a bolus on induction for pediatric scoliosis cases.

I use a bolus dose upon hitting the OR (0.2 mg/kg, max of 20 mg); only for adolescent idiopathic scoli cases, not the neuromuscular kiddos.

 

[MirrorTodd]

Hmm? What does context sensitive half time have to do with an upfront bolus?

That was in response to the infusion question.

 

[repititionition]

I use a good sized oral dose in preop for complex spine surgery (multilevel with hardware, redo, etc). As was stated earlier this practice is supported in the literature.

why oral? pharmacodynamics are extremely variable compared to IV.

 

[IDGARA]

why oral? pharmacodynamics are extremely variable compared to IV.

In my situation, we didn't have IV on formulary, or it was too much of a hassle for pharmacy to draw it up.

 

[Blockit]

why oral? pharmacodynamics are extremely variable compared to IV.

True. Pharmacy won’t stock IV.

 

[lotsapain]

I give between 0.1 - 0.25 mg/kg IBW at induction, never part of a protocol.
I do this for all kinds of cases, not just spines.

That is indeed the dosing recently discussed at the ASA meeting as well as a single bolus. Works quite well, methadone is making a comeback.

 

[PpfSuxTube]

That was in response to the infusion question.

Funny way of wording it. Confused me a bit. Take advantage of the worst part of something that technically doesn't even exist in the modality you suggest

 

[pocafx]

I give between 0.1 - 0.25 mg/kg IBW at induction, never part of a protocol.
I do this for all kinds of cases, not just spines.

What other cases do you give it for? And do the patients require more narcotic?

 

[Beeftenderloin]

What other cases do you give it for? And do the patients require more narcotic?

I know I wasn’t asked, but I’m sharing because I feel like this drug
Is massively underutilized. I routinely use methadone for all large spines, non-emergent laparotomies that aren’t getting an epidural (which is most at my shop), all cardiac cases and I’ve just recently starting to use it more in my thoracic practice as well. Big fan.

 

[Dr. Rude]

I know I wasn’t asked, but I’m sharing because I feel like this drug
Is massively underutilized. I routinely use methadone for all large spines, non-emergent laparotomies that aren’t getting an epidural (which is most at my shop), all cardiac cases and I’ve just recently starting to use it more in my thoracic practice as well. Big fan.

Are you using it at all in patients who are going home same day?

 

[PpfSuxTube]

I know I wasn’t asked, but I’m sharing because I feel like this drug
Is massively underutilized. I routinely use methadone for all large spines, non-emergent laparotomies that aren’t getting an epidural (which is most at my shop), all cardiac cases and I’ve just recently starting to use it more in my thoracic practice as well. Big fan.

Why cardiac? Dont they end up on precedex, dilaudid or fentanyl infusion in the icu anyway?

 

[nimbus]

Why cardiac? Dont they end up on precedex, dilaudid or fentanyl infusion in the icu anyway?

Not if things went well.

 

[repititionition]

I know I wasn’t asked, but I’m sharing because I feel like this drug
Is massively underutilized. I routinely use methadone for all large spines, non-emergent laparotomies that aren’t getting an epidural (which is most at my shop), all cardiac cases and I’ve just recently starting to use it more in my thoracic practice as well. Big fan.

I use methadone on about a quarter of my total case volume, including same day surgeries.

 

[gasman19]

Thank you for the responses!

 

[Beeftenderloin]

Why cardiac? Dont they end up on precedex, dilaudid or fentanyl infusion in the icu anyway?

More findings by Murphy et. al. Cardiac surgery patients got less morphine post-op, improved patient perceived quality of pain management, and reduced pain scores out to 30 days post op. No change in opioid related adverse events. Its one of the few things I can do as an anesthesiologist on the day of surgery where I feel like the benefit I’m providing can be measured in days to weeks and not minutes to hours.

 

[SRYSPAC]

I use methadone on about a quarter of my total case volume, including same day surgeries.

Why do you need a 24-72 hour tail of analgesic coverage for same day surgeries? Honest question; I'm all for patients looking amazing in PACU, but is the feedback from this population such that everyone should consider some methadone in ASCs?

 

[MirrorTodd]

Funny way of wording it. Confused me a bit. Take advantage of the worst part of something that technically doesn't even exist in the modality you suggest

Ya I'm a bit of a joker that way. The residents seem to love it.

 

[Dr. Rude]

Why do you need a 24-72 hour tail of analgesic coverage for same day surgeries? Honest question; I'm all for patients looking amazing in PACU, but is the feedback from this population such that everyone should consider some methadone in ASCs?

One subset of patient that I have used methadone for twice with trepidation- Outpatient ortho 1 ankle fusion and 1 shoulder who had contraindications for blocks.

 

[anbuitachi]

Single 0.3mg/kg bolus up front. This dosing is supported by literature (Murphy et al.) for reduciing pain after spine surgery out to 90 days post-op. Occasionally I go down to 0.2mg/kg if they're more frail appearing. Infusion sounds kinda bonkers for a drug with a 24hr half-life.

so 30mg for a 100kg patient? my patient tomorrow is 150kg, getting ankle surgery. dont think i'll be able to do great blocks since his leg is messed up and its also massive. methadone may be a good choice. 45mg bolus seems like a lot upfront. i havent done methadone in a while.

we sometimes do duramorph spinals for ex laps, but maybe i should just bolus methadone

 

[Block-Buster]

anyone used it for total knee replacements?

 

[Dr. Rude]

so 30mg for a 100kg patient? my patient tomorrow is 150kg, getting ankle surgery. dont think i'll be able to do great blocks since his leg is messed up and its also massive. methadone may be a good choice. 45mg bolus seems like a lot upfront. i havent done methadone in a while.

we sometimes do duramorph spinals for ex laps, but maybe i should just bolus methadone

Dosing recommendations is based on ideal body weight. Not actual body weight.

 

[Beeftenderloin]

so 30mg for a 100kg patient? my patient tomorrow is 150kg, getting ankle surgery. dont think i'll be able to do great blocks since his leg is messed up and its also massive. methadone may be a good choice. 45mg bolus seems like a lot upfront. i havent done methadone in a while.

we sometimes do duramorph spinals for ex laps, but maybe i should just bolus methadone

I use adjusted body weight on anyone with a BMI >30. Very high BMI I would probably use IBW for added safety margin, especially if patient is going home. Admittedly I have never given more than 30mg. Maybe I should. But pharmacy starts giving me a hard time at around 25mg and I’m not trying to fix all their pain, just have a nice baseline of narcotic for the first couple days after painful surgery.

I still use duramorph in spinals for OB (intsitutional inertia), but that population aside I believe there is no role for intrathecal morphine. Methadone is far superior. You get longer pain control. The respiratory depression peaks at ~30-60 min, while patient is still closely monitored, unlike duramorph where they often get peak respiratory depression while unmonitored on a regular floor. Methadone also has NMDA receptor antagonism and some mild SNRI activity in addition to its mu opioid agonist activity, while duramorph just work works on mu. Plus you don’t need to poke their back and case gets under way 5 minutes sooner.

 

[ketorolac]

I use adjusted body weight on anyone with a BMI >30. Very high BMI I would probably use IBW for added safety margin, especially if patient is going home. Admittedly I have never given more than 30mg. Maybe I should. But pharmacy starts giving me a hard time at around 25mg and I’m not trying to fix all their pain, just have a nice baseline of narcotic for the first couple days after painful surgery.

I still use duramorph in spinals for OB (intsitutional inertia), but that population aside I believe there is no role for intrathecal morphine. Methadone is far superior. You get longer pain control. The respiratory depression peaks at ~30-60 min, while patient is still closely monitored, unlike duramorph where they often get peak respiratory depression while unmonitored on a regular floor. Methadone also has NMDA receptor antagonism and some mild SNRI activity in addition to its mu opioid agonist activity, while duramorph just work works on mu. Plus you don’t need to poke their back and case gets under way 5 minutes sooner.

Would you consider methadone instead of intrathecal morphine in OB patients?

 

[Beeftenderloin]

Would you consider methadone instead of intrathecal morphine in OB patients?

No data to back it up, but my experience with the 2 meds tells me methadone would likely be superior. I would probably get looked at like I have 3 heads the first OB patient I gave it to though. Plus our work flow doesn’t support it and I’m not the guy who’s going to die fighting to make that happen with no data.

 

[nimbus]

Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations

This Clinical Focus Review provides an assessment of clinical investigations that have evaluated the effect of intraoperative methadone on postoperative outcomes. Postoperative pain and need for analgesics can be significantly reduced with intraoperative methadone.

pubs.asahq.org

 

[abolt18]

so 30mg for a 100kg patient? my patient tomorrow is 150kg, getting ankle surgery. dont think i'll be able to do great blocks since his leg is messed up and its also massive. methadone may be a good choice. 45mg bolus seems like a lot upfront. i havent done methadone in a while.

we sometimes do duramorph spinals for ex laps, but maybe i should just bolus methadone

Typically maxed at 30mg. Never given more. Even with that they're going to be pretty out of it in my experience.

 

[repititionition]

anyone used it for total knee replacements?

Yes. Most of them.

Overall, many get 10 to15. Some get 20. Very few get more from me, barring very special cases like huge spines, patients on high baseline opioid regimen, etc.

 

[IDGARA]

What other cases do you give it for? And do the patients require more narcotic?

Pretty much any case I can't do a block on. It could be 5mg for a lap chole, 10 for bariatric stuff, you name it.
I would look sometimes at what kind of narcotics patients required in PACU, and it often wasn't much at all. But I never looked at this systematically. But the methadone was part of a a multimodal thing I'd do for everyone: acetaminophen, celecoxib, and methadone preop, maybe 100mcg of fentanyl at induction, and then PRN stuff in PACU. I figured if we're going to give a long acting narcotic anyways (oxy, hydromorphone, morphine), why not give one with a long half life that has some solid evidence behind it?

And yes, I'll give this to outpatient as well (this is touched on in the Murphy review article). Mostly just 5 or 10 mg PO (that's all we had at one place.) There was a dose finding study in Anesthesiology recently that settled on 0.25 mg/kg of IBW for same day and next day discharge. Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study

I had one patient with three open fractures (two wrists and an ankle) that the orthopod decided to fix in one go. I did no bocks, gave 20 mg of methadone plus some boluses of fentanyl, and the guy left PACU after 30 minutes.

 

[GassYous]

Pretty much any case I can't do a block on. It could be 5mg for a lap chole, 10 for bariatric stuff, you name it.
I would look sometimes at what kind of narcotics patients required in PACU, and it often wasn't much at all. But I never looked at this systematically. But the methadone was part of a a multimodal thing I'd do for everyone: acetaminophen, celecoxib, and methadone preop, maybe 100mcg of fentanyl at induction, and then PRN stuff in PACU. I figured if we're going to give a long acting narcotic anyways (oxy, hydromorphone, morphine), why not give one with a long half life that has some solid evidence behind it?

And yes, I'll give this to outpatient as well (this is touched on in the Murphy review article). Mostly just 5 or 10 mg PO (that's all we had at one place.) There was a dose finding study in Anesthesiology recently that settled on 0.25 mg/kg of IBW for same day and next day discharge. Intraoperative Methadone in Next-day Discharge Outpatient Surgery: A Randomized, Double-blinded, Dose-finding Pilot Study

I had one patient with three open fractures (two wrists and an ankle) that the orthopod decided to fix in one go. I did no bocks, gave 20 mg of methadone plus some boluses of fentanyl, and the guy left PACU after 30 minutes.

Why can't you do blocks on the bariatrics? Quick and less opioids are good for the f

 

[IDGARA]

Why can't you do blocks on the bariatrics? Quick and less opioids are good for the f

What block would you do for a lap bariatric case? I never got much experience on sub costal TAPs.

 

[MirrorTodd]

What block would you do for a lap bariatric case? I never got much experience on sub costal TAPs.

Just practice the TAP, could do ESP as well but those are a hassle from a positioning standpoint. QL may work too but I don't know if you'd get coverage high enough.