amt of fentanyl in epidural

[Gas you down]

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i got a call re: lethagy in a post thoracotomy pt. partner put epidural in, 0.25% bupi w/ fentanyl 20 mcg/cc @ 6cc/hr. this sounded absurdly high to me. i questioned him the next day, and he and the other old guys said thats what they always used. i KNOW this dose is excessive, but was wondering what you guys think is your limit as far as fentanly epidural dosage. i was thinking 5mcg/cc.

 

[dhb]

i got a call re: lethagy in a post thoracotomy pt. partner put epidural in, 0.25% bupi w/ fentanyl 20 mcg/cc @ 6cc/hr. this sounded absurdly high to me. i questioned him the next day, and he and the other old guys said thats what they always used. i KNOW this dose is excessive, but was wondering what you guys think is your limit as far as fentanly epidural dosage. i was thinking 5mcg/cc.

At that level you can skip the bupi.
If your intent is to run the epidural with local anesthetics then yes 5mcg/cc of fent is enough.

 

[jwk]

5mcg/cc is our routine for fentanyl - but your 0.25% bupivicaine is way high as well - our routine pre-fills from pharmacy are 0.075%.

 

[sevoflurane]

Thoracic epidural>Rib retractor>Snap, crackle, pop!>.2% Rop with 2mcg/ml fent @ 6ml/hr. at T5ish.
If no snap/crackle/pop then .125% marcaine with 2mcg/ml fent.
Paravertebrals is another option and they work well... although not quite as well as a well placed thoracic epidural IMO (T.Epidurals have more side effects than a PVB however.)

 

[Gas you down]

5mcg/cc is our routine for fentanyl - but your 0.25% bupivicaine is way high as well - our routine pre-fills from pharmacy are 0.075%.

i agree! I will gently make a few suggestions to my partners...

 

[pgg]

i got a call re: lethagy in a post thoracotomy pt. partner put epidural in, 0.25% bupi w/ fentanyl 20 mcg/cc @ 6cc/hr. this sounded absurdly high to me. i questioned him the next day, and he and the other old guys said thats what they always used. i KNOW this dose is excessive, but was wondering what you guys think is your limit as far as fentanly epidural dosage. i was thinking 5mcg/cc.

I wonder if those guys trained at the same place as our guy who just gave 1 mg of intrathecal morphine.


We have pre-mixed bags of 2 mcg/mL fentanyl in 0.125% bupivacaine that we use for both OB and postop surgical patients.

 

[sevoflurane]

I wonder if those guys trained at the same place as our guy who just gave 1 mg of intrathecal morphine.

Whoa....! 😱

 

[PMPMD]

I wonder if those guys trained at the same place as our guy who just gave 1 mg of intrathecal morphine.


We have pre-mixed bags of 2 mcg/mL fentanyl in 0.125% bupivacaine that we use for both OB and postop surgical patients.

😱

 

[pgg]

In fairness, sort of, it was later acknowledged as an error.

(Part of the unfortunated circumstances that led to my TKA cocktail question in the private forum.)

 

[epidural man]

i got a call re: lethagy in a post thoracotomy pt. partner put epidural in, 0.25% bupi w/ fentanyl 20 mcg/cc @ 6cc/hr. this sounded absurdly high to me. i questioned him the next day, and he and the other old guys said thats what they always used. i KNOW this dose is excessive, but was wondering what you guys think is your limit as far as fentanly epidural dosage. i was thinking 5mcg/cc.

Maybe he was lethargic from his 70/palp blood pressure from his 0.25% thoracic epidural.

 

[cincincyreds]

Yeah, I think Bupi .1% and fentanyl 2mcq/cc in the bag is more reasonable than you described. That is our mix in ob.

 

[RxBoy]

pt. partner put epidural in, 0.25% bupi w/ fentanyl 20 mcg/cc @ 6cc/hr.

I've gotten burned with an upper thoracic running even 5 mcg on the elderly at 6cc an hour. I usually run 2.5/0.075 and titrate rate accordingly.

And 0.25 bupivacaine is insanely high. I mean that concentration is approaching a surgical epidural, it probably is with that much fentanyl. Might as well just shut off the gas.

Not to mention there is probably some pretty significant bradycardia with a .25/20 mcg mix. Blocking the cardiac acceleraters (T1-4) with local while stimulating the parasympathetics with the opiate. Might kill someone with significant AR on OLV.

Maybe it was 20 mcg of dilaudid?

 

[Gas you down]

I've gotten burned with an upper thoracic running even 5 mcg on the elderly at 6cc an hour. I usually run 2.5/0.075 and titrate rate accordingly.

And 0.25 bupivacaine is insanely high. I mean that concentration is approaching a surgical epidural, it probably is with that much fentanyl. Might as well just shut off the gas.

Not to mention there is probably some pretty significant bradycardia with a .25/20 mcg mix. Blocking the cardiac acceleraters (T1-4) with local while stimulating the parasympathetics with the opiate. Might kill someone with significant AR on OLV.

Maybe it was 20 mcg of dilaudid?

BP was 110/80, normal HR. level turned out to be T7 and below. i turned down epi fentanyl conc and she started having pain. so cut the bupi in half and bolused it up big-time. seemed to work fine after that.

 

[Oggg]

our entry level bag is 0.1% bupiv and fent 4mcg/cc.

 

[RxBoy]

level turned out to be T7 and below. i turned down epi fentanyl conc and she started having pain.

There lays the problem. T7 level is too low for a good epidural. Per Miller:

If you were getting a T7 level and assuming 4 cm feed in with most the 6cc/hr solution moving cephalad, the congruent epidural catheter placement was probably T10 or below. I think switching solutions to dilaudid to take advantage of the spread would work well.

The fentanyl is probably working simply because with epidural fentanyl, serum levels are equal to that of IV fentanyl. And at 120 mcg/hr its a pretty good PCA basal dose.