Enhanced recovery and early extubation after pediatric cardiac surgery using single-dose intravenous methadone

Abstract

Background/aims: Methadone may offer advantages in facilitating early extubation after cardiac surgery, but very few data are available in the pediatric population.

Setting/design: Community tertiary children's hospital, retrospective case series.

Materials and methods: We performed a retrospective analysis of all pediatric cardiac surgical patients for whom early extubation was intended. A multimodal analgesic regimen was used for all patients, consisting of methadone (0.2-0.3 mg/kg), ketamine (0.5 mg/kg plus 0.25 mg/kg/h), lidocaine (1 mg/kg plus 1.5 mg/kg/h), acetaminophen (15 mg/kg), and parasternal ropivacaine (0.5 mL/kg of 0.2%). Outcome variables were collected with descriptive statistics.

Results: A total of 24 children [median = 7 (interquartile range = 3.75-13.75) years old, 23.7 (14.8-53.4) kg] were included in the study; 22 (92%) had procedures performed on bypass and 11 (46%) involved a reentry sternotomy. Methadone dosing was 0.26 (0.23-0.29) mg/kg. None of the children required intraoperative supplemental opioids; 23 (96%) were extubated in the operating room. The first p_aCO₂ on pediatric intensive care unit admission was 51 (45-58) mmHg. Time to first supplemental opioid administration was 5.1 (3.5-9.5) h. Cumulative total supplemental opioids (in intravenous morphine equivalents) at 24 and 72 h were 0.2 (0.09-0.32) and 0.42 (0.27-0.68) mg/kg. One child required postoperative bilevel positive airway pressure support, but none required reintubation. None had pruritus; three (13%) experienced nausea.

Conclusion: A methadone-based multimodal regimen facilitated early extubation without appreciable adverse events. Further investigations are needed to confirm efficacy of this regimen and to assess whether the excellent safety profile seen here holds in the hands of multiple providers caring for a larger, more heterogeneous population.

Keywords: ERAS; Early extubation; enhanced recovery; enhanced recovery after surgery; fast-track extubation; methadone; operating room extubation; pediatric cardiac surgery; pediatric open heart surgery.

Figure 1

First recorded p_aCO₂ on PICU admission. Heavy dashed line represents median; light dashed line represents interquartile range. Arrow denotes patient who required rescue bilevel positive airway pressure

Figure 2

Time in hours from extubation to first supplemental opioid administration. Heavy dashed line represents median; light dashed line represents interquartile range