case - options for pain control

[Norepi]

I wouldn’t do this. Methadone has a long half life and will still be around after the patient leaves. You need a special license to prescribe it. Americans like to abuse drugs. If one of these patients decides to take a couple of extra oxycodone from their prescription and dies, how’s that methadone going to look?

This is some galaxy brain s*it here
Researcher 1: hey let's try to minimize opioids in same day surgery, the US is a huge outlier in this regard
Researcher 2: hey what if instead we gave a F*CK TON of a nontitratable opioid???

The only times I've used methadone are for those on chronic methadone use

Intraoperative Methadone in Surgical Patients | Anesthesiology | American Society of Anesthesiologists

anesthesiology.pubs.asahq.org

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial - PubMed

Intraoperative methadone administration reduced postoperative opioid requirements, decreased pain scores, and improved patient satisfaction with pain management.

pubmed.ncbi.nlm.nih.gov

Not even in spines? It's demonstrably better in spine cases than remi/dilaudid, and will at least let you cut down on intraop remi use and NMDA antagonize to oppose OI-hyperalgesia.

These data show that there are no immediate postoperative complications, and these patients were followed for weeks + postop even at home and they used less opioids, were more satisfied in house and after discharge. Yes you may know that methadone is empirically "hard to dose", or variable in terms of pharmacokinetics, but these data show that the danger is perhaps less than you think - none of these patients had postop depression!

Also, the opioid is titratable, as the study that I first cited showed nurses dosing methadone at 2 mg increments in the PACU. At low doses (as seen in the ASA paper), it behaves like morphine and is short-acting, depending on where you are on the analgesia and apnea response curve.

The data doesn't lie. It may feel unsafe, but it's clearly obviously beneficial - at least consider it for patients who will be admitted for 1-several days (especially your spine patients.)

 

[dipriMAN]

Intraoperative Methadone in Surgical Patients | Anesthesiology | American Society of Anesthesiologists

anesthesiology.pubs.asahq.org

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial - PubMed

Intraoperative methadone administration reduced postoperative opioid requirements, decreased pain scores, and improved patient satisfaction with pain management.

pubmed.ncbi.nlm.nih.gov

Not even in spines? It's demonstrably better in spine cases than remi/dilaudid, and will at least let you cut down on intraop remi use and NMDA antagonize to oppose OI-hyperalgesia.

These data show that there are no immediate postoperative complications, and these patients were followed for weeks + postop even at home and they used less opioids, were more satisfied in house and after discharge. Yes you may know that methadone is empirically "hard to dose", or variable in terms of pharmacokinetics, but these data show that the danger is perhaps less than you think - none of these patients had postop depression!

Also, the opioid is titratable, as the study that I first cited showed nurses dosing methadone at 2 mg increments in the PACU. At low doses (as seen in the ASA paper), it behaves like morphine and is short-acting, depending on where you are on the analgesia and apnea response curve.

The data doesn't lie. It may feel unsafe, but it's clearly obviously beneficial - at least consider it for patients who will be admitted for 1-several days (especially your spine patients.)

I get the impression that methadone is “in” for some reason at the moment. As is the term “opioid induced hyperalgesia” despite the fact that there is no way to distinguish it from tolerance in the immediate post op period. I’d prefer to use a traditional morphone or hydromorphone, given in equipotent doses you’ll get the same effect as the methadone. I would never write for methadone to be given q20 min IV in the PACU by the PACU nurses, frankly this seems like your just asking for trouble.

 

[coffeebythelake]

Not even in spines? It's demonstrably better in spine cases than remi/dilaudid, and will at least let you cut down on intraop remi use and NMDA antagonize to oppose OI-hyperalgesia.

Sufentanil 0.3-0.5 mcg/kg/hr
+/- ketamine 3-5 mcg/kg/min.

Yes you can do neuromonitoring and EMG, MEP with the above.
The addition of ketamine (when used from the beginning) can help boost your baseline amplitude signals and potentially increase its sensitivity.

Why would you ever use remifentanil for a big spine case with a ton of postop pain? Just silly.

 

[SnapperRocks]

Intraoperative Methadone in Surgical Patients | Anesthesiology | American Society of Anesthesiologists

anesthesiology.pubs.asahq.org

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, Controlled Trial - PubMed

Intraoperative methadone administration reduced postoperative opioid requirements, decreased pain scores, and improved patient satisfaction with pain management.

pubmed.ncbi.nlm.nih.gov

Not even in spines? It's demonstrably better in spine cases than remi/dilaudid, and will at least let you cut down on intraop remi use and NMDA antagonize to oppose OI-hyperalgesia.

These data show that there are no immediate postoperative complications, and these patients were followed for weeks + postop even at home and they used less opioids, were more satisfied in house and after discharge. Yes you may know that methadone is empirically "hard to dose", or variable in terms of pharmacokinetics, but these data show that the danger is perhaps less than you think - none of these patients had postop depression!

Also, the opioid is titratable, as the study that I first cited showed nurses dosing methadone at 2 mg increments in the PACU. At low doses (as seen in the ASA paper), it behaves like morphine and is short-acting, depending on where you are on the analgesia and apnea response curve.

The data doesn't lie. It may feel unsafe, but it's clearly obviously beneficial - at least consider it for patients who will be admitted for 1-several days (especially your spine patients.)

I’m going to go with a hard no for methadone in outpatient surgery. I think you should read this and seriously reconsider the safety of what you’re doing. There is a wide variation in both patient response and elimination half life which is 15-55 hours. Respiratory depression peaks later than analgesia peak. Anticipated response to other narcotics given concomitantly is unpredictable. I think it is inappropriate to have nurses dose it like morphine unsupervised. I hope your surgeons are aware that you’re giving it if they’re prescribing further sedatives for home on top of it. I am frankly happy the drugs I prefer in the OR wear off predictably in a couple of hours. Do you warn your patients they have an opiate that may last several days in their system? Could that effect their driving?

Keeping Patients Safe From Methadone Overdoses

“Methadone differs from other opioids in several important ways:

• Variability in the drug’s absorption, metabolism, and relative analgesic potency among patients calls for a highly individualized approach to prescribing. Particular vigilance is necessary during treatment initiation and titration.1
• Although methadone’s duration of analgesic action for single doses (four to eight hours) approximates that of morphine, methadone’s half-life is substantially longer than that of morphine (eight to 59 hours vs. one to five hours).1
• Methadone’s peak respiratory depressant effects typically occur later and persist longer than its peak analgesic effects.1
  
  As a result of methadone’s dosing complexities and other contributing factors, the FDA, the Institute for Safe Medication Practices (ISMP), and ISMP Canada have received multiple reports of medication errors involving methadone that have resulted in serious patient harm, including fatalities. Methadone represents fewer than 5% of total opioid prescriptions dispensed but one-third of opioid-related deaths nationwide.3

Prescribing

• The concomitant use of methadone should be avoided with other narcotics, benzodiazepines, and sedatives, because these agents significantly increase the risk of AEs. If patients must take these medications with methadone, the starting dose and the speed of titration for methadone may need to be adjusted downward.
• It might be prudent to restrict ordering privileges for methadone to prescribers with expertise in managing chronic pain and narcotic addiction.

 

[dhb]

Why would you ever use remifentanil for a big spine case with a ton of postop pain? Just silly.

Why would you use sufentanil? It's only 20min better.

 

[SnapperRocks]

Why would you use sufentanil? It's only 20min better.

They’re different drugs. Remi hangs around until it doesn’t and 60 seconds later you find out whether or not you had enough longer acting opiate around for pain control. Sufentanil wears off slower and is harder to time your wake up but they usually wake up comfortable and the tail gives you time to titrate opiates while they’re awake.

 

[Arch Guillotti]

Why would you use sufentanil? It's only 20min better.

remi is horrendous for big spine cases.

 

[coffeebythelake]

Why would you use sufentanil? It's only 20min better.

Is this a serious question?

20 min difference?? I refer you to any pharmacology source on context sensitive decrement time.

 

[dhb]

Is this a serious question?

20 min difference?? I refer you to any pharmacology source on context sensitive decrement time.

Well of course if you are giving a boatload you're going to fill the tank.
0.3-0.5mcg/kg/h is a ridiculous dosage (probably from your great pharmacology source).

 

[coffeebythelake]

Well of course if you are giving a boatload you're going to fill the tank.
0.3-0.5mcg/kg/h is a ridiculous dosage (probably from your great pharmacology source).

Ridiculous? Seriously? have you never done a big spine case before?? Have you ever used sufentanil before??

The dose I quoted is actually on the lower end for sufentanil dosing so it isn't a "boatload" that will "fill the tank" as you say.

For a typical 8 hour high risk spine, we usually start at 0.8-1 mcg/kg/h and then titrate down during the case to 0.3-0.5 mcg/kg/h, then stop the infusion on closing.

For the frail patients we start at 0.3-0.5 mcg/kg/h, and even these patients get a lot more than "20 minutes" of pain relief postop.




And since you specifically and incredulously declared that sufentanil provides "20 minutes" more pain relief than remifentanil, you must realize you are not speaking of a single context sensitive half-time at the effector site, but rather to multiple half-times. That's why I suggested you refer to a basic pharmacology source. It doesn't have to be great. Any one would be sufficient.

 

[Arch Guillotti]

Well of course if you are giving a boatload you're going to fill the tank.
0.3-0.5mcg/kg/h is a ridiculous dosage (probably from your great pharmacology source).

uh, no.

 

[dhb]

0.4mcg/kg for 80kg is 32mcg/h which to me is a ridiculously high dose.
Do you get a badge for doing big spine cases?

 

[coffeebythelake]

0.4mcg/kg for 80kg is 32mcg/h which to me is a ridiculously high dose.
Do you get a badge for doing big spine cases?

Just admit you are wrong. Correcting you over and over is exhausting.

Are you an anesthesiology attending? Resident? (CRNA?) Did you enroll in an ACGME accredited anesthesiology residency? I don't know if this is a serious knowledge gap or maybe you are just a trainee (although I doubt a resident would speak with such arrogance and self assurredness).

The more you respond the more obvious it is you haven't used sufentanil and have no idea the proper dosing. And yet you feel compelled to insert your foot in mouth by expressing your opinions. Relearn your pharmacology. You have no clue.

 

[dipriMAN]

Just admit you are wrong. Correcting you over and over is exhausting.

Are you an anesthesiology attending? Resident? (CRNA?) Did you enroll in an ACGME accredited anesthesiology residency? I don't know if this is a serious knowledge gap or maybe you are just a trainee (although I doubt a resident would speak with such arrogance and self assurredness).

The more you respond the more obvious it is you haven't used sufentanil and have no idea the proper dosing. And yet you feel compelled to insert your foot in mouth by expressing your opinions. Relearn your pharmacology. You have no clue.

I typically would max out at 0.3 mcg/kg/hr, simply because people never seemed to ever need more than that. I agree that people always wake up pretty easily if you turn it off at that dose at an appropriate time, never had any significant delayed wake ups.

 

[GassYous]

That's about 2-5 mcg/h of sufent which is about 10 times stronger than fentanyl. So maybe 20-50 mcg/h of fent which is a baby dose.

 

[dipriMAN]

That's about 2-5 mcg/h of sufent which is about 10 times stronger than fentanyl. So maybe 20-50 mcg/h of fent which is a baby dose.

Not sure where your getting those numbers. It ends up being about 20-30 mcg of sufentanil ever hour for maitinance, with bolus at the beginning of the case, usually 100mcg vial is sufficient for most cases unless an all day thing.

 

[coffeebythelake]

I typically would max out at 0.3 mcg/kg/hr, simply because people never seemed to ever need more than that. I agree that people always wake up pretty easily if you turn it off at that dose at an appropriate time, never had any significant delayed wake ups.

The problem with starting off at 0.3 mcg/kg/hr is that you need to develop a reasonable plasma concentration quickly to prevent movement and bucking for the preflip motors, and the same when pinning head and proning. Some anesthesiologists bolus sufentanil then back off on the gtt. Other anesthesiologists run higher gtt then titrate down. Obviously the bigger and more painful the surgery, the higher the requirements. The numbers I've provided in previous post.

 

[dipriMAN]

The problem with starting off at 0.3 mcg/kg/hr is that you need to develop a reasonable plasma concentration quickly to prevent movement and bucking for the preflip motors, and the same when pinning head and proning. Some anesthesiologists bolus sufentanil then back off on the gtt. Other anesthesiologists run higher gtt then titrate down. The numbers I've provided in previous post.

Agreed. I typically always bolus at induction.

 

[coffeebythelake]

That's about 2-5 mcg/h of sufent which is about 10 times stronger than fentanyl. So maybe 20-50 mcg/h of fent which is a baby dose.

you're an order of magnitude off in your conversion.

0.3-0.5 mcg/kg/hr for an 80 kg patient is 24-40 mcg/hr sufentanil
assuming it is 5-10x more potent than fentanyl, that turns out to be somewhere between 150-400 mcg/hour of fentanyl equivalent

 

[dhb]

Just admit you are wrong. Correcting you over and over is exhausting.

I have no problem admitting i'm wrong i'm just not sure about what here.
You haven't corrected anything but you did tell me to read a book, thank you very much.
Is 80×0.4 not equal to 32mcg/h? I used to do a CABG with 25mcg.
So yes in my view 32mcg/h for a 5h case is more than 150mcg if you bolus at induction and run the infusion higher at the start which is an enormous amount.

 

[coffeebythelake]

I have no problem admitting i'm wrong i'm just not sure about what here.
You haven't corrected anything but you did tell me to read a book, thank you very much.
Is 80×0.4 not equal to 32mcg/h? I used to do a CABG with 25mcg.
So yes in my view 32mcg for a 5h case is more than 150mcg if you bolus at induction and run the infusion higher at the start which is an enormous amount.

Your grade 4 level arithmetic isn't wrong. Yeah, 80x0.4 = 32. But that's not what we are disagreeing with, is it?

Your idea of appropriate dosing is completely wrong. What you call a "ridiculous" high dose of sufentanil for a spine case is laughable. The sufentanil is being used as "table glue" for these big spine cases where they monitor motors. You understand the specific anesthestic requirements needed for that? Let me put it another way. You use muscle relaxant with your CABG? Think about that for a minute. Do I need to explain further?

If you still dont get it and want me to spell it out let me know.

Smh

 

[abolt18]

Your grade 4 level arithmetic isn't wrong. Yeah, 80x0.4 = 32. But that's not what we are disagreeing with, is it?

Your idea of appropriate dosing is completely wrong. What you call a "ridiculous" high dose of sufentanil for a spine case is laughable. The sufentanil is being used as "table glue" for these big spine cases where they monitor motors. You understand the specific anesthestic requirements needed for that? Let me put it another way. You use muscle relaxant with your CABG? Think about that for a minute. Do I need to explain further?

If you still dont get it and want me to spell it out let me know.

Smh

Why so confrontational? dhb is a long time contributor who practices anesthesia across the pond and often offers an interesting and different perspective to anesthetizing patients. Experience with a drug that is so different from yours does not necessitate insults.

Take a chill pill.

 

[coffeebythelake]

Why so confrontational? dhb is a long time contributor who practices anesthesia across the pond and often offers an interesting and different perspective to anesthetizing patients. Experience with a drug that is so different from yours does not necessitate insults.

Take a chill pill.

I responded in kind to dhbs taunts. I will apologize for asking if he/she is a resident or crna, since that doesn't appear to be the case. I'm done.

 

[GassYous]

you're an order of magnitude off in your conversion.

0.3-0.5 mcg/kg/hr for an 80 kg patient is 24-40 mcg/hr sufentanil
assuming it is 5-10x more potent than fentanyl, that turns out to be somewhere between 150-400 mcg/hour of fentanyl equivalent

Whoops, that's what happens when you don't use sufent a lot and also suck at math.

 

[SaltyDog]

The sufentanil is being used as "table glue" for these big spine cases where they monitor motors.

I think many of you drastically overestimate how much opioid is required to keep these patients glued to the table.

 

[abolt18]

I think many of you drastically overestimate how much opioid is required to keep these patients glued to the table.

Agreed. I've run sufenta for these spines and usually run the dose at 1/4 to 1/2 of what people have described. (0.1-0.2mcg/kg/hr)

 

[Urzuz]

I think many of you drastically overestimate how much opioid is required to keep these patients glued to the table.

^ this x 1000

I left all opioid infusions (along with all the other ridiculous infusions that would leave a patient’s EEG isoelectric) back in residency.

Propofol + Ketamine infusions, maybe lidocaine if I’m feeling extra frisky. Give some fentanyl/dilaudid at the beginning, titrate more in at end prn.

I don’t think people realize how little stimulation there is in these cases after exposure...

 

[coffeebythelake]

Agreed. I've run sufenta for these spines and usually run the dose at 1/4 to 1/2 of what people have described. (0.1-0.2mcg/kg/hr)

With no loading dose and no muscle relaxant? On half MAC of gas and some propofol? Somehow I suspect there is something seriously amiss in that formula. I imagine for some patients you wouldn't get much further than pinning or postflip motors before they start responding and moving to stimuli. You can do a conversion to remifentanil gtt or another more commonly used opioid equivalent if you want to see what I'm saying. (Hint: giving 0.1 mcg/kg sufentanil is like giving an 80 kg patient a 40-80 mcg dose of fentanyl-- and you want to give that 0.1 mcg/kg of sufenta over 1 hour??). i know this because even when I load patients up with sufentanil and run them at my standard doses some of them still move.

Also can't believe I have to say this obvious fact again and again, the patient particulars as well as type and extent of spine surgery affects the intraop opioid requirements. For both table glueing and for postoperative pain needs -- the goal is to ensure patient remains still during operation and to have good lasting pain relief postop without significant delays in emergence. BOTH of these things. That is quite easily achievable at the doses I described earlier. When the patient is extubated and does not have significant pain for hours after an 8 hour, 6 level spine surgery i consider that a success and not a "ridiculous" sufentanil overdose. To make this point even more clear, I suggest you look up commonly used sufentanil dosing (based on both studies and clinical anecdotes) for spine surgeries and not necessarily subscribe to the lowest possible dose. A quick 30 second google search landed this study, which involved giving spinal surgery patients mean dose of 126.3 mcg sufentanil over mean time of 150 minutes, with good cardiovascular stability, rapid emergence of anesthesia, and no postop respiratory depression. Evaluation of sufentanil as a supplement to anaesthesia in lengthy spinal surgery - PubMed Other studies are out there if you want to look for them.

Finally, if you are going to use a ton of roc as your table glue during exposure and other parts of the surgery, you ain't really using sufentanil as table glue are ya?

 

[nimbus]

I’ve never heard of table glue until today.

 

[coffeebythelake]

^ this x 1000

I left all opioid infusions (along with all the other ridiculous infusions that would leave a patient’s EEG isoelectric) back in residency.

Propofol + Ketamine infusions, maybe lidocaine if I’m feeling extra frisky. Give some fentanyl/dilaudid at the beginning, titrate more in at end prn.

I don’t think people realize how little stimulation there is in these cases after exposure...

It isn't the opioid infusions that are causing your patient's EEG to be isoelectric...
if you don't want your pt in burst suppression...
you should probably be backing off on your propofol gtt...

 

[Urzuz]

It isn't the opioid infusions that are causing your patient's EEG to be isoelectric...
if you don't want your pt in burst suppression...
you should probably be backing off on your propofol gtt...

maybe you misunderstood what I wrote. I’m saying that in my experience, in academic centers, they run a ridiculous number of infusions that make for unnecessarily complex anesthetics. The isoelectric EEG comment was more tongue in cheek, but even then I never suggested that opioids are the cause of that...?

 

[coffeebythelake]

maybe you misunderstood what I wrote. I’m saying that in my experience, in academic centers, they run a ridiculous number of infusions that make for unnecessarily complex anesthetics. The isoelectric EEG comment was more tongue in cheek, but even then I never suggested that opioids are the cause of that...?

your sentence structure (particularly with the word "other") might lead one to interpret an isoelectric EEG as being caused by opioids and all the other ridiculous infusions.

 

[Urzuz]

your sentence structure (particularly with the word "other") might lead one to interpret an isoelectric EEG as being caused by opioids and all the other ridiculous infusions.

Is this guy ****ing for real? Lmao

 

[epidural man]

You guys who are critical of intraoperative methadone need to do some more reading.

Single dose methadone on induction is an EXCELLENT choice for this patient. I would highly recommend it.

Your goal for this patient is to prevent them from needing opioids post op. Those who claim this isn’t a painful procedure and the patient won’t hurt - I think - are not being honest about their experience taking care of fibromyalgia patients on opioids. This patient is going to wake up in an incredible amount of pain if this scenario is not managed properly.

Methadone could be key in this endeavor.

I should also add, ALL the warnings of Methadone come from chronic use, not a single dose. I would suggest that when pasting scary verbiage about methadone from a source - that you make sure they are talking in context about a single IV dose, and leave anything else that doesn’t even come close to applicable.

 

[SaltyDog]

Your goal for this patient is to prevent them from needing opioids post op.

By giving them opioids pre-op??

 

[epidural man]

By giving them opioids pre-op??

Like I said, if interested (and no skin of anyone’s teeth if you don’t want to learn about it), read more about the wonders of single dose IV perioperative methadone use.