2026 Southeastern Residency Conference

Title: Evaluation of intraoperative intravenous methadone administration for cardiothoracic surgery analgesia 
Author(s): Anna Carlson, Nevena Mihalovich, Ethan Gerrald, Zachary Klick, Paige Behr, Madison Fielding, Akshara Patel; Atrium Health Wake Forest Baptist, Winston Salem, NC 

Objective: To evaluate the efficacy and safety of intravenous (IV) methadone as adjunctive analgesia in cardiothoracic surgery (CTS)
  
Background:  Post-operative opioid stewardship has been a focus of national and state level initiatives to curtail the prescribing of excessive opioid analgesics. The use of multimodal analgesics is recommended by the Society of Thoracic Surgery (STS) to reduce morphine milligram equivalents (MME). Pain following CTS is typically most severe within the first 24 hours postoperatively but may persist for several days. To effectively manage postoperative pain, methadone has been used intraoperatively due to its favorable pharmacokinetic profile, including its long half-life of 24-36 hours. Previous studies comparing methadone with shorter-acting opioids suggest reductions in pain scores and MME requirements in patients receiving intraoperative IV methadone. However, studies vary among types of surgery performed, reported opioid-related adverse events, and postoperative day (POD) study follow-up duration. Additional research is warranted to quantify the impact of intraoperative IV methadone and support practice optimization. 

Methods: This was a retrospective, single-center, cohort study utilizing electronic health record (EHR) data of patients undergoing CTS, including coronary artery bypass graft (CABG), aortic valve repair (AVR), isolated mitral valve repair or replacement (MVR/MVr), aortic root repair or replacement, or other combinations thereof. Data was collected utilizing an EHR report to identify CTS performed from March 2024 – August 2025. Patients were categorized into two groups: intraoperative IV methadone administration for adjunctive analgesia or standard of care. Key exclusion criteria are preoperative gastrointestinal obstruction (including ileus), mechanical circulatory support after index surgery, continuous infusion opioids within 48 hours prior to CTS, or active or prior opioid use disorder. The primary endpoint was average cumulative MME requirements through POD four or discharge, whichever comes first. Secondary endpoints include difference in daily MME requirements, incidence of naloxone rescue administration, intraoperative MME requirements, percentage of patients extubated within 6 and 24 hours, incidence of postoperative ileus, incidence of opioid-related adverse effects, and opioids prescribed at discharge in MME.  
Baseline characteristics assessed were age, sex, comorbidities, and type of CTS performed, as well as use of antiarrhythmic medications, glucagon-like-peptide-1 receptor agonists, and opioid, including methadone, use within 30 days. Results were analyzed utilizing descriptive statistics, with means or medians reported for continuous variables as appropriate. Categorical endpoints were analyzed using Fisher’s exact or chi-square test for normally distributed data.  
 
Results: 200 patients in total were included (IV methadone n=100; standard of care n=100). Baseline characteristics were similar between the two groups aside from a statistically significant difference in incidence of depression. There were no significant differences in type of CTS or number of adjunctive analgesic agents used postoperatively. Cumulative POD 0-4 MME were significantly lower in the methadone group compared with standard of care (167 vs 209; mean difference 42; p=0.046). Reductions in MME requirements were most notable on POD 0 and POD 1 (mean difference 16 and 19, respectively; p=0.006). There were no observed differences in incidence of naloxone administration, extubation within 6 and 24 hours, postoperative delirium, or ICU length of stay. Mean MME prescribed at discharge was significantly lower in the methadone group (126 vs 135 MME; p=0.0047).  
 
Conclusions: Administration of intraoperative IV methadone significantly reduces postoperative MME requirements when compared to standard of care.