Dilaudid vs Fentanyl

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
M

Mike1228

Full Member
2+ Year Member
Joined
Nov 7, 2020
Messages
17
Reaction score
5
The common theme I see in clinical is that the opioid of choice 99% of the time is Fentanyl. I understand why, its most hemodynamically stable, fast onset, doesn't stick around forever, predictable, easy to titrate/push based on vital signs, pretty much no active metabolites.....but shouldn't pretty much everyone get Dilaudid, not Fentanyl, when waking up in the OR. Why give something that's gonna wear off (given that you've stayed under 200 mcg total) pretty much 10 mins after you drop the patient off in PACU? Why not give like 0.5 mg Dilaudid when waking up, or even 0.2 mg increments at a time if you're worried about snowing a patient??
Ps: is it reasonable to consider Precedex a "long-term" analgesic replacement to Dilaudid in today's world?
Members don't see this ad.
 
Mike1228 said:
The common theme I see in clinical is that the opioid of choice 99% of the time is Fentanyl. I understand why, its most hemodynamically stable, fast onset, doesn't stick around forever, predictable, easy to titrate/push based on vital signs, pretty much no active metabolites.....but shouldn't pretty much everyone get Dilaudid, not Fentanyl, when waking up in the OR. Why give something that's gonna wear off (given that you've stayed under 200 mcg total) pretty much 10 mins after you drop the patient off in PACU? Why not give like 0.5 mg Dilaudid when waking up, or even 0.2 mg increments at a time if you're worried about snowing a patient??
Ps: is it reasonable to consider Precedex a "long-term" analgesic replacement to Dilaudid in today's world?
Click to expand...

What is your background and qualifications?

And to answer your question: how much opioid a patient receives prior to "waking up" is dependent on how much postop pain you expect they will have. I don't know where you have this idea that nobody gives dilaudid because it is given in 100% of my cases when I feel the patient will need it.

Also precedex is an adjunct. It helps. It is not a replacement for opioid analgesia.
 
Yeah most of my patients get dilaudid and fentanyl. Fent for intubation and surgical incision. Dilaudid 30-40 minutes prior to extubation. I'm also a fan of having some background dilaudid (0.4-0.6mg) and then titrating small amount of fentanyl prior to extubation, that works well and is safe if you're not heavy handed.
 
Members don't see this ad :)
coffeebythelake said:
What is your background and qualifications?

And to answer your question: how much opioid a patient receives prior to "waking up" is dependent on how much postop pain you expect they will have. I don't know where you have this idea that nobody gives dilaudid because it is given in 100% of my cases when I feel the patient will need it.

Also precedex is an adjunct. It helps. It is not a replacement for opioid analgesia.
Click to expand...
I feel I just see most give Fentanyl and then Dilaudid is given by PACU nurses after patient is dropped off and mostly awake....you give "when patient will need it", but fentanyl will do the same thing as dilaudid (which is what most Anesthesiologists I see use only) but had shorter duration and let they let PACU give the Dilaudid....are you saying you'll give Dilaudid so the PACU nurses won't have to give as much? Because it's not like Dilaudid is more potent, it'll just have longer DOA because less redistribution. Fentanyl is significantly more potent as sure most people already know. Preceptors just tell me to give Fentanyl based on respiratory rate while waking up to bridge them to PACU and then let PACU give Dilaudid since then you can have the patient actually tell you how much pain they're in (less likely to over-narcotize when patients is awake). Sorry if this is a dumb concept/question but it's bothering me. People always make it seem like Dilaudid is stronger "since they save it for big painful surgeries" but it's not stronger at all, it just lasts longer. It's how you use it based on equivalent doses.
Btw, I didn't mean using precedex to replace all narcotics, I mean just Dilaudid. Precedex for those smoothe vital signs and Fentanyl for stimulating times, induction, and emergence. To have a short acting and long acting analgesic on board
 
I've been doing a lot of: fentanyl for induction, ketamine and precedex combo intraop, and fentanyl on emergence according to respiratory rate...along with toradol/decadron/Tylenol if not contraindicated. Of course not every case, but for a lot of cases. Sometimes I'll substitute for ketamine or precedex in patients that should avoid it.
 
I give hydromorphone to almost every case I expect to have postop pain enough to warrant an outpatient opioid script on discharge, minimum 0.5 mg unless they are ancient, tiny, delirious, or sick patients, etc. For a more painful and longer surgery, I will give hydromorphone before induction and skip any fentanyl altogether.
 
Skribbles said:
Because it makes wasting a nonissue.
Click to expand...

Well I suppose it makes sense to give that last 50 mcg fentanyl on emergence rather than to pop open and draw up a new vial of dilaudid. But if you were doing a painful case I would hope you had the foresight to actually have prepared that dilaudid earlier.
 
Personally, if it's a longer case, I'll just give 1mg hydromorphone at the start. Another mid-case if I feel it's warranted. By the time the case ends, patient is comfy, coasting to the finish line.
 
abolt18 said:
Personally, if it's a longer case, I'll just give 1mg hydromorphone at the start. Another mid-case if I feel it's warranted. By the time the case ends, patient is comfy, coasting to the finish line.
Click to expand...
That's a long case? 2mg of Dilaudid??... Are we talking about 12 hrs long or 2 hrs long
 
Members don't see this ad :)
anbuitachi said:
That's a long case? 2mg of Dilaudid??... Are we talking about 12 hrs long or 2 hrs long
Click to expand...
Obviously it also depends on the surgery and the amount of dissection/anticipated pain, but my point was just that I like to give a bigger dose (everyone was talking about 0.2mg or 0.5mg doses) early and let it ride. The actual time is irrelevant.
 
anbuitachi said:
This 100 percent. We only have 2mg Dilaudid vials. And wasting requires me to find a witness!
Click to expand...
seems like you are saying you are OK providing a suboptimal anesthetic because of convenience / laziness

if the system makes it more difficult to go about your practice, maybe some change needs to take place with the system.
 
coffeebythelake said:
seems like you are saying you are OK providing a suboptimal anesthetic because of convenience / laziness

if the system makes it more difficult to go about your practice, maybe some change needs to take place with the system.
Click to expand...
That’s easy to say but unrealistic. My system has a drug czar whose sole purpose is to analyze controlled substance usage - including time between withdrawal and administration/wastage. I had to explain why I accessed and wasted so much morphine on a day I did 5 C-sections…. Our OR nurses claim they can’t waste with us (even though they have Pyxis access), I think because they don’t want their names attached to the stuff. So yes, “convenience” matters when a mistake can seriously impact your career.
 
Name of the game is turnover time and keep the day moving. I feel those patients with dilaudid have a longer wake up time. Obviously if it’s a very painful surgical case I will give it , but the average gallbladder , cysto.. I don’t .
 
med2010 said:
That’s easy to say but unrealistic. My system has a drug czar whose sole purpose is to analyze controlled substance usage - including time between withdrawal and administration/wastage. I had to explain why I accessed and wasted so much morphine on a day I did 5 C-sections…. Our OR nurses claim they can’t waste with us (even though they have Pyxis access), I think because they don’t want their names attached to the stuff. So yes, “convenience” matters when a mistake can seriously impact your career.
Click to expand...

Your anesthesja department needs to grow some balls and rein it in. This "czar" needs to be dethroned. And when you bring up patient care, poor patient satisfaction and suboptimal pain control as a systems related issue that is largely due to an overbearing individual that might change the narrative. There are easier and better ways to account for narcotics. It doesn't have to be so onerous.
 
PlayToWin said:
Name of the game is turnover time and keep the day moving. I feel those patients with dilaudid have a longer wake up time. Obviously if it’s a very painful surgical case I will give it , but the average gallbladder , cysto.. I don’t .
Click to expand...

It only takes longer if you don't know how to titrate your anesthetic. Either you are giving too much dilaudid too late in the process, or you are turning off your gas too late.
 
med2010 said:
That’s easy to say but unrealistic. My system has a drug czar whose sole purpose is to analyze controlled substance usage - including time between withdrawal and administration/wastage. I had to explain why I accessed and wasted so much morphine on a day I did 5 C-sections…. Our OR nurses claim they can’t waste with us (even though they have Pyxis access), I think because they don’t want their names attached to the stuff. So yes, “convenience” matters when a mistake can seriously impact your career.
Click to expand...
Why does it seem like the OB nurses are the same no matter where you go?
 
coffeebythelake said:
Your anesthesja department needs to grow some balls and rein it in. This "czar" needs to be dethroned. And when you bring up patient care, poor patient satisfaction and suboptimal pain control as a systems related issue that is largely due to an overbearing individual that might change the narrative. There are easier and better ways to account for narcotics. It doesn't have to be so onerous.
Click to expand...
This czar was brought in by the highest level of administration to reduce the system’s liability related to the opioid crisis. They oversee controlled substance use everywhere, not just the anesthesia department, across multiple hospitals. You’re living (or maybe working) in a dream world if you think admin cares about anything more than covering their own ass.
 
med2010 said:
This czar was brought in by the highest level of administration to reduce the system’s liability related to the opioid crisis. They oversee controlled substance use everywhere, not just the anesthesia department, across multiple hospitals. You’re living (or maybe working) in a dream world if you think admin cares about anything more than covering their own ass.
Click to expand...

So the admin thinks that a lot of your staff is stealing drugs? Seems like a big problem at your hospital indeed. I agree that this only creates an illusion of proper accounting for narcotics. So many ways to get around it when the only thing your drug czar look for are numbers on a spreadsheet.

You know what else admin should (but doesn't appear to) worry about aside from liability? Poor patient satisfaction survey scores. Slowed OR efficiency. Poor staff morale for ineffective measures.
 
Last edited:
Eras non-opioid practice has changed my thoughts on Dilaudid versus Fentanyl. Opioid naive big belly case I give 30 ketamine up front then titrate fentany at the end. If patients have received opioids preop than i give dilaudid for short belly cases appys choles etc… I like loading 1mg at the beginning and reassesing at 2.5 hrs where the case is going.
 
I use fentanyl in small doses but I have gotten away from using it throughout a case due to concern of OIH (opioid induced hyperalgesia). The phenomenon is even more pronounced the shorter acting the opioid so I would rather use a longer acting opioid combined with ketamine to possibly blunt or avoid this problem. Fentanyl is good for blunting hemodynamic responses to intensely stimulating events such as intubation or incision but it isn’t great to just keep bolusing if throughout a case. This is my 2 cents but I am sure there are a myriad of opinions on this subject.
 
I practice similarly to everyone. For cases that I think are not very painful like ercp, I give esmolol on induction and give no opioids. Case with a good block (brachial plexus, ankle, etc), no opioids. I give fentanyl for the 1 hour outpatients. For the longer cases and slower surgeons I like to skip the fent and give 1 of dilaudid upfront. For longer cases like robots or spine, I give fentanyl upfront and titrate in dilaudid.
 
My biggest annoyance is people giving massive underdoses of hydromorphone for painful surgeries. Ex lap, CRNA gives 0.2 mg hydromorphone towards the end of the case and expects patient to wake up ok. GETA total knee or hip, same thing. It’s barbaric. No one in their right mind would say they would want to be treated that way. I am all for limiting fentanyl, but not giving a longer acting opioid for painful surgeries is terrible.
 
coffeebythelake said:
It only takes longer if you don't know how to titrate your anesthetic. Either you are giving too much dilaudid too late in the process, or you are turning off your gas too late.
Click to expand...
Maybe but I’ve also had simple cases, just fentanyl up front and it took like 15-20 minutes to wake patient up. No rhyme or reason sometimes … just don’t want to take a chance unless patient needs it.
 
PlayToWin said:
Maybe but I’ve also had simple cases, just fentanyl up front and it took like 15-20 minutes to wake patient up. No rhyme or reason sometimes … just don’t want to take a chance unless patient needs it.
Click to expand...

Turn the gas and/or prop off 15-20 minutes earlier?

Also they don't need to be filling out crosswords to be extubated
 
Justice4all said:
We have the opposite problem here. 0.5mg dilaudid for 15 minute EGD and they wonder why can’t wake up
Click to expand...
The most common reason someone checks out Dilaudid for GI cases is diversion.

(my n=1 experience)
 
Where I trained over 10yrs ago, we almost never used any other opioid than fentanyl intraoperatively so that's how I learned; and I don't recall being called much by the PACU nurses for post-op pain issues. honestly, in the past 10yrs I've done it both ways (fentanyl only vs fentanyl/dilaudid or fentanyl/morphine) and I still don't think there's a huge difference. anecdotally obviously, but i think it's possible to titrate fentanyl intraoperatively such that you can have a comfortable patient in PACU whose post-op pain can be easily managed by the PACU nurse.
i'm curious though, why the front loading of dilaudid in longer cases vs just titrating from middle/end of case instead of fentanyl early on?
 
leaverus said:
Where I trained over 10yrs ago, we almost never used any other opioid than fentanyl intraoperatively so that's how I learned; and I don't recall being called much by the PACU nurses for post-op pain issues. honestly, in the past 10yrs I've done it both ways (fentanyl only vs fentanyl/dilaudid or fentanyl/morphine) and I still don't think there's a huge difference. anecdotally obviously, but i think it's possible to titrate fentanyl intraoperatively such that you can have a comfortable patient in PACU whose post-op pain can be easily managed by the PACU nurse.
i'm curious though, why the front loading of dilaudid in longer cases vs just titrating from middle/end of case instead of fentanyl early on?
Click to expand...

1628284587657.png


agree. my patients with fentanyl are very comfortable in the pacu
 
Of course it doesn't matter. Many ways to skin a cat. If there was a proven method, everyone would do it the same way. As often in medicine, it depends on your patient, procedure, surgeon, etc.
 
We drop off patients in PACU, and leave 19 minutes later. The PACU nurses are loading people up with butloads of hydromorphone. I’ve heard from many PACU nurses over time that patients are easier to control for them if Yoj give hydromorphone rather than only fentanyl.
 
leaverus said:
Where I trained over 10yrs ago, we almost never used any other opioid than fentanyl intraoperatively so that's how I learned; and I don't recall being called much by the PACU nurses for post-op pain issues. honestly, in the past 10yrs I've done it both ways (fentanyl only vs fentanyl/dilaudid or fentanyl/morphine) and I still don't think there's a huge difference. anecdotally obviously, but i think it's possible to titrate fentanyl intraoperatively such that you can have a comfortable patient in PACU whose post-op pain can be easily managed by the PACU nurse.
i'm curious though, why the front loading of dilaudid in longer cases vs just titrating from middle/end of case instead of fentanyl early on?
Click to expand...
Me neither.. I had zero experience with dilaudid when i finished residency. It was Fentanyl exclusively intraop and morphine in pacu.
When someone mentioned they gave dilaudid intra op when I finsihed.. I was like what is that? We use way too much narcotic intra op EVERYWHERE>
 
  • Like
Reactions: dhb
coffeebythelake said:
So i am curious how you make that assessment.

Are you saying patients are getting too much opioids and that it is somehow harmful to them?

What does your statement even mean?
Click to expand...
The less you use them the more you realize that they are, in general, a very unnecessary part of an anesthetic.
 
You must log in or register to reply here.

Similar threads

P
White House Medical Unit ordering fentanyl, ketamine, morphine
Replies
14
Views
2K
Arantius
A
DesiredMemberName?
“Fentanyl Vaccine”
Replies
12
Views
1K
DrOwnage
DrOwnage
M
Versed and fentanyl for sedation
2
Replies
63
Views
5K
Twiggidy
Twiggidy
GolDRoger
Cardiology vs. Anesthesia
Replies
35
Views
4K
lotsapain
L
D
Optimal fentanyl and morphine dose for CS spinal.
Replies
36
Views
2K
sevoflurane
sevoflurane
Top