Improving postoperative pain management after minimally invasive coronary surgery using methadone analgesia and early...

Effective analgesia management after cardiac surgery is critical to postoperative care. Inadequate pain management leads to delayed mobilization and prolonged hospital stay. Analgesia protocols for minimally invasive coronary surgery have not been standardized. The primary aim of this study was to evaluate the impact of an enhanced recovery after cardiac surgery (ERACS) protocol, combining methadone-based analgesia and early chest drain removal, on postoperative opioid consumption in patients undergoing endoscopic-assisted coronary artery bypass grafting (Endo-CAB) compared to the standard recovery after cardiac surgery (SRACS) for both Endo-CAB and off-pump coronary artery bypass grafting (OPCAB) via sternotomy.

This single-center retrospective cohort study included all single-vessel Endo-CAB and OPCAB procedures performed between December 2018 and March 2025. Patients undergoing redo surgery, concomitant arrhythmia procedures, conversion to sternotomy, or those with major complications affecting postoperative analgesia were excluded. The ERACS protocol consisted of methadone-based intraoperative analgesia and early chest drain removal compared with standard recovery care.

A total of 340 patients were included: 118 Endo-CAB ERACS, 111 Endo-CAB SRACS, and 111 OPCAB SRACS. Endo-CAB patients had significantly postoperative lower opioid use than Endo-CAB SRACS patients [44 (15.0-85.0) vs. 62 (35.0-91.0) morphine equivalent (MeQ), P=0.009] and OPCAB SRACS patients [44 (15.0-85.0) vs. 75 (75.0-115.0) MeQ, P<0.001]. Drain duration was shorter in ERACS patients [4.7 (3.6-6.2) vs. 22.8 (19.1-26.1) and 23.3 (18.2-27.0) hours, P<0.001]. Multivariable analysis showed longer procedural time and older age were associated with lower opioid use, while prolonged drain time and higher body mass index predicted increased use.

ERACS with methadone and early drain removal significantly reduced opioid consumption and drain duration in Endo-CAB patients compared to standard care, including OPCAB.