Intraoperative Methadone: A New Enhanced Recovery After Surgery Pathway for Deep Inferior Epigastric Perforator Flap...

Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. Previous studies have shown that just one dose of methadone can achieve better analgesia than multiple doses of short-acting opioids. This study aims to evaluate the effectiveness of our Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator flap breast reconstruction centered around a single weight-based intraoperative dose of methadone.

The authors retrospectively reviewed patients from October 2020 to March 2021 to establish a historical control cohort (n = 29). The ERAS protocol was implemented in April 2021, and patients were prospectively enrolled in the ERAS cohort from April 2021 to January 2022 (n = 54). Primary outcomes compared between the ERAS and historical cohorts using univariate analysis were length of stay, postoperative opioid consumption, pain scores, heart rates, and incidence of tachycardia.

There was no difference in the length of stay between our ERAS and non-ERAS cohorts (P = 0.68). Patients in the ERAS pathway had significantly less opioid consumption at 12 hours postoperatively (P < 0.001), 24 hours postoperatively (P < 0.001), and throughout the entire admission (P = 0.002). Pain scores were significantly lower in the ERAS cohort at 24 hours postoperatively (P = 0.021) and throughout admission (P = 0.0051). The ERAS cohort had significantly lower heart rates at 12 hours postoperatively (P = 0.0014), 24 hours postoperatively (P < 0.001), and throughout admission (P < 0.001). The incidence of tachycardia was also significantly lower in the ERAS cohort (P = 0.029).

This preliminary data after newly instituting our ERAS protocol with a single dose of intraoperative methadone significantly reduced postoperative opioid analgesic usage, pain scores, heart rates, and incidence of tachycardia. This pilot study demonstrates that methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease postoperative pain, opioid use, and increase overall patient comfort and satisfaction.