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This is not sound practice for many reasons which I dont have time to elucidate cuz im getting ready go and where Im goin there is no internet.
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Dilaudid vs Fentanyl
Started by Mike1228
My question is why even bother giving diluadid intra op when fentanyl is that much more potent intraop, leave the longer acting stuff to the recovery room. Again i NEVER give dilaudid intraop.
A few of you guys seem oddly dogmatic. More of a nuanced answer is in order. Some procedures require none or virtually no opiate. Others a few small doses of fentanyl. Most exquisitely painful procedures benefit from hydromorphone.
Anesthesiology had a recent cover story on “opioid sparing”/“opiate free” treatment regimens. The trial had to be aborted early because one of the arms (precedex arm) had so many serious adverse cardiac side effects.
So perhaps the take home is “opiate sparing” is not necessarily safer than judicious/appropriate use of opiates.
Anesthesiology had a recent cover story on “opioid sparing”/“opiate free” treatment regimens. The trial had to be aborted early because one of the arms (precedex arm) had so many serious adverse cardiac side effects.
So perhaps the take home is “opiate sparing” is not necessarily safer than judicious/appropriate use of opiates.
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Also just learn how to use them all. Opioids are all equally efficacious (edit for typo/clarity) if you give the right doses. Only relevant differences are metabolites/metabolism and half life.
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Last time I fell off my snowboard, just hooked myself up to an esmolol drip and I was good
When you are unconscious under GA you don't feel pain. So yeah esmolol works for that.
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deleted875186
I don’t believe this. I think it is very hard to find equipotent doses between fentanyl and traditional full agonists because fentanyl is so much faster on and off, and much more potent. The time course is totally different.
look at the outpatient conversion for a fentanyl patch, 50 mcg/hr is a 120 oral MME conversion. I think we give very big doses of fentanyl, and unfortunately very small doses of long acting opioid for cases when postoperative pain is going to be significant. If Yoj believe in opioid induced hyperalgesia, or even just tolerance developing after repeated fentanyl doses, your not helping the patient by giving more fentanyl during surgery.
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deleted875186
On the other hand, it makes life easy for the anesthesiooogist, I agree it’s much easier for me to just give more fentanyl, I don’t have to think as much and it’s more forgiving if I give too much, but making my life easier doesn’t mean it’s the best thing for the patient.
there is no difference in efficacy if you give the right dose. There are merely differences in pharmacodynamics. I assure you if you push 50 mg of hydromorphone on somebody, it is going to have the same efficacy as whatever dose of fentanyl you want to give. I mean they might not wake up for a while afterwards, but you can rest assured the effect will be maximal.
Not familiar with that trial but is that because no opioids were used or because the substitute for the opioid was precedex?
how about the practice of titrating Narcotics to Respiratory rate at the end of the case... Oh brother!!!!! talk about misguided.. You will invariably overdose the patient with this method in my opinion.
Is this your opinion? Or you have any evidence to back this up
I said it is my opinion. Do you have any evidence to suggest the contrary?
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Anesthesiology
Explore Anesthesiology, featuring peer‑reviewed articles, clinical studies, and the latest medical research.
Very interesting study and commentary. (Also a good accompanying editorial by Evan Kharasch.)
No but it is something that quite a few qanesthesiologists do. And since you are the one making bold claims about overdosing patients I think you ought to be able to qualify your statement rather than asking someone to defend a fairly common practice.
You're so wrong here its not even worth explaining.
Why am i wrong?
rate of 6 works great . no complaints in pacu
Also don’t forget different settings necessitate different pain management. If you titrate opiates to RR6 at the ASC your private group staffs, you won’t be going to said ASC for long.
These places want people wide awake a few minutes after a GA (room air, talking). Whatever the case is.
At the hospital go ahead and extubate everyone deep and bring them over well narcotized.
To the young guns: get very comfortable practicing in different environments and understanding how to keep everyone happy in these different practice environments. Be adaptable and not dogmatic and stubborn. My 2c…
These places want people wide awake a few minutes after a GA (room air, talking). Whatever the case is.
At the hospital go ahead and extubate everyone deep and bring them over well narcotized.
To the young guns: get very comfortable practicing in different environments and understanding how to keep everyone happy in these different practice environments. Be adaptable and not dogmatic and stubborn. My 2c…
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deleted875186
I also disagree with this.
if by efficacy you mean immediate pain control, then yes. But I don’t think we have enough info about other outcomes, like postop pain control on the floor after using hydromorphone or fentanyl intraop, opioid use lostop , more importantly opioid use needed at discharge as an outpatient, incidence of chronic pain from surgery …. Etc.
there is evidence that methadone use in cardiac surgery rather than fentanyl, and methadone in major spine surgery rather than hydromorphone leads to less chronic pain after leaving the hosptial. Saying all opioids are equal just different kinetics is an oversimplification.
and yes I know methadone is a different opioid, but perhaps consider that maybe part of the difference in outcomes above is because methadone is so long acting, proving sometimes 3 days of pain relief after a single big bolus, suggesting maybe long acting is the key rather than the often quoted NMDA effects of methadone.
I think we lack a lot of info about opioids because historically we just think of them as equal when used at equipotent doses.
and a co2 of 115
What's up with the esmolol obsession? I use it maybe twice a year.
I was never heavy handed on opiods and kept reducing their use overtime to the point where i was giving 5mcg of sufenta. Then it was like what's the point of microdosing and i stopped giving it 99% of the time with absolutely no difference. I actually think that by avoiding unnecessary opiod receptor occupation during GA you get a much better response should you have to give an analgesic in PACU.
I guess it's hard for people that are so used to giving opiods to imagine an anesthetic without them.
I extubate at RR>25 all the time without any problems.
Ps; i'll say it before someone else goes for the jugular: my patients are always in great pain in Pacu, they stay longer in Pacu and need an overnight admit at 10x the normal rate and generally are all very upset and angry at me for making them suffer terribly.
Not a great study, can't really blame the opiod free technique as the reason for bradycardia upon insuflation.Anesthesiology
Explore Anesthesiology, featuring peer‑reviewed articles, clinical studies, and the latest medical research.pubs.asahq.org
Very interesting study and commentary. (Also a good accompanying editorial by Evan Kharasch.)
I 've been following this thread and as I curious trainee I would like to ask @dhb and others striving to reduce opioids .. How do you control hemodynamics/nociception/pain? without opioid? Even with some cloni/paracetamol/nsaid vitals get nasty when I go low on fentanyl, especially during laparoscopic surgery, (unless pt is deep >1.2 MAC of des which cant be good especially for elderly I guess?).
At this point I will usually give a little labetalol but sometimes I feel bad/like torturing the patient. I guess it's all philosophical about what pain really is?
At this point I will usually give a little labetalol but sometimes I feel bad/like torturing the patient. I guess it's all philosophical about what pain really is?
you are referring to things related to pharmacodynamics and metabolism, not efficacy as defined in a pharmacological sense of the word as I am referring.
This! Exactly how I practice, and I ask for the PACU nurses routinely how things go in PACU and anything I could do better.
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deleted875186
I’m not referring to pharmacokinetics. I’m suggesting the ultra short acting more potent opioid leads to rapid tolerance, making patient use higher doses when awake and days later. Perhaps this is what explains the lower incidence of chronic pain 6 months out from surgery in the studies done with methadone.
I've had several patients who have had rrs in the 20s for shoulder surgery. Low TVs and etco2 high 30s-low 40s. Take the lma out, they are talking to me a minute later. Zero pain. I try to titrate opioids to etco2 on sv, not rr.
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Esmolol infusion
Is that what you titrate to? I'm talking about giving dilaudid when patients RR is 30 and MV is 12 on a half MAC of gas
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deleted875186
I find that the RR does not necessarily predict pain, shallow rapid breathing happens during emergence and with GA under gas.
I do find that the RR let’s me titrate opioids to the point where the patient will not be apnic.
I always dose based on my prediction of how much postop pain there will be, which is about 50% based on the procedure and 50% based on how mature and reasonable the patient is and if they have had pain issues.
I don't use it either. But you can for intubation or HR BP spikes when the patient is anesthetized in lieu of opioid. Blunt the sympathetic responses. Since a bunch of people here on this board are opioid nazis I brought up this point.
When thr patient is zonked out from your anesthetic they will probably report minimal discomfort immediately after extubation. Wait 15 minutes and reassess.. your PACU nurses will probably hate you when you big exlap comes out after having received 100 mcg fentanyl.
So no esmolol and no opioids either huh. There is actually some evidence that esmolol infusions reduce postop pain. If you are going to give such an esoteric rationale for not giving opioids would have imagined you would be more open to nonopioid adjuncts.
It's not a "problem" if you don't care about pain. Or unless their BP and HR is so high that they stroke out or have a heart attack.
Minute ventilation
Not just RR
You are correct there is a big difference between a patient taking rapid shallow breathing as expected with inhaled anesthetic, vs a patient hyperventilating spontaneously with high RR and MV.
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Check out the Big Brain on Brad!!!!!!!!!!!!!!
Do not worry about what the Pacu nurses think of you. My priority is patient safety not making the pacu nurses happy Which is hard to do as a matter of fact!! Bringing someone to the pacu oral airway in place does not make me a happy person. And my happiness is more important than the pacu nurses
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Yeah for shorter cases, I just give 1 mg with dexamethasone and ondansetron near beginning of case. Foll
MY observations and experience:
I try to use opioids judiciously mainly because the side effects are morbid for people and it risks them staying longer in PACU. That said, I think they are entirely appropriate to use. I find myself using fentanyl much more than dilaudid because in most soft-tissue non-visceral cases immediate surgical pain stays short lived. I tend to dilaudid when I anticipate the pain lasting longer and it's going to be a challenge for the surgeon to apply local anesthetic to cover it: which tends to be bone-work or visceral pain.
I try my best to get smart about it. Most somatic pain will be in the dermis and doesn't tend to persist in a severe fashion after the surgical insult, which is severe. Fentanyl tends to be good enough for this because it is a rapid response to a rapid stimulus and goes away shortly after that. When watching the surgeon infiltrate local I observe how they inject their local. If they inject too deep I don't think it does much if anything to cover pain because the pain receptors are going to be dermal. Visceral and bone pain, I believe, tend to persist for longer and aren't manageable by surgeon-injected local, so they'll require either the right PNB or something longer-acting like dilaudid/methadone.
I'm a regionalist and really believe in the power of the PNB. I prefer pre-op blocks as it reduces / eliminates intraop and PACU opioid requirements making wakeups faster and side-effects less in the PACU. If I have a solid block (patient has no hemodynamic response to incision, unchanged RR pattern when spontaneous) then I let RR ride to higher numbers without giving narcotic. Higher RRs is usually due to long tourniquet times or rapid shallow breathing from volatile anesthetic.
In my mind, it boils down to being thoughtful: what am I actually treating with my intervention? the patient, or a number?
I try to use opioids judiciously mainly because the side effects are morbid for people and it risks them staying longer in PACU. That said, I think they are entirely appropriate to use. I find myself using fentanyl much more than dilaudid because in most soft-tissue non-visceral cases immediate surgical pain stays short lived. I tend to dilaudid when I anticipate the pain lasting longer and it's going to be a challenge for the surgeon to apply local anesthetic to cover it: which tends to be bone-work or visceral pain.
I try my best to get smart about it. Most somatic pain will be in the dermis and doesn't tend to persist in a severe fashion after the surgical insult, which is severe. Fentanyl tends to be good enough for this because it is a rapid response to a rapid stimulus and goes away shortly after that. When watching the surgeon infiltrate local I observe how they inject their local. If they inject too deep I don't think it does much if anything to cover pain because the pain receptors are going to be dermal. Visceral and bone pain, I believe, tend to persist for longer and aren't manageable by surgeon-injected local, so they'll require either the right PNB or something longer-acting like dilaudid/methadone.
I'm a regionalist and really believe in the power of the PNB. I prefer pre-op blocks as it reduces / eliminates intraop and PACU opioid requirements making wakeups faster and side-effects less in the PACU. If I have a solid block (patient has no hemodynamic response to incision, unchanged RR pattern when spontaneous) then I let RR ride to higher numbers without giving narcotic. Higher RRs is usually due to long tourniquet times or rapid shallow breathing from volatile anesthetic.
In my mind, it boils down to being thoughtful: what am I actually treating with my intervention? the patient, or a number?
I'll weigh in on a few things about my way of doing it. Obviously, multimodal approaches using things with minimal side effects like nerve blocks and acetaminophen are great when possible. Otherwise, I do try to use hydromorphone for painful surgeries, usually upfront too to prevent sensitization and upregulation of receptors in the pain pathway.
Regarding efficacy, opioids are all just as efficacious if you understand how to dose them appropriately to reach effective concentrations. Fentanyl wears off so fast that it's just hard to reach any kind of steady-state for longer surgeries unless you're dosing it really frequently or start an infusion, which is just a pain. Play around with using an app like iTIVA and you'll see how much easier it is to keep things relatively steady with hydromorphone than fentanyl. Morphine is even better in this sense but a little less forgiving with metabolism time unless you're really sure you aren't overdosing somebody. Hydromorphone just seems to be the most convenient for timing.
Everybody talks about the undesirable effects of opioids, but little is often said of the desirable effects other than pain control postoperatively. Opioids provide some extra amnestic effect to supplement the anesthetic gas, allowing less of it to be needed, leading to less delirium, hypotension, nausea, and quicker (and smoother) wakeups. It also helps prevent people from moving in cases without neuromuscular blockade and helps prevent against intraoperative laryngospasm and bronchospasm.
For emergency cases I sometimes don't use opioids until the end if I suspect hypotension will be a challenge.
Overall, people are being a little to dogmatic here. Opioids can be helpful, and of course it's possible to overdo them. Every case may call for a different approach.
And for what little it's worth, PACU nurses also tell me they appreciate my patients generally being more comfortable, not nauseated, and quickly wakeful. I suspect that a lot of this is due to slightly more opioid use than some and a lot less volatile use. Or maybe I only hear their compliments and never the complaints, but who knows?
Regarding efficacy, opioids are all just as efficacious if you understand how to dose them appropriately to reach effective concentrations. Fentanyl wears off so fast that it's just hard to reach any kind of steady-state for longer surgeries unless you're dosing it really frequently or start an infusion, which is just a pain. Play around with using an app like iTIVA and you'll see how much easier it is to keep things relatively steady with hydromorphone than fentanyl. Morphine is even better in this sense but a little less forgiving with metabolism time unless you're really sure you aren't overdosing somebody. Hydromorphone just seems to be the most convenient for timing.
Everybody talks about the undesirable effects of opioids, but little is often said of the desirable effects other than pain control postoperatively. Opioids provide some extra amnestic effect to supplement the anesthetic gas, allowing less of it to be needed, leading to less delirium, hypotension, nausea, and quicker (and smoother) wakeups. It also helps prevent people from moving in cases without neuromuscular blockade and helps prevent against intraoperative laryngospasm and bronchospasm.
For emergency cases I sometimes don't use opioids until the end if I suspect hypotension will be a challenge.
Overall, people are being a little to dogmatic here. Opioids can be helpful, and of course it's possible to overdo them. Every case may call for a different approach.
And for what little it's worth, PACU nurses also tell me they appreciate my patients generally being more comfortable, not nauseated, and quickly wakeful. I suspect that a lot of this is due to slightly more opioid use than some and a lot less volatile use. Or maybe I only hear their compliments and never the complaints, but who knows?
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deleted697127
This is questionable.
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deleted875186
I agree … if your worried about delirium, minimal opioid, light anesthesia, maybe a BIS.
We all do it, because it makes sense, but where the actual evidence? The AWARE trials were a bit meh
Yeah I don't know about the anti-nausea or faster-wakeup effects of opioids, but as far as delirium goes, I will say that I believe most of the delirium attributed to desflurane wakeups is nothing more than opioid deficiency.
Iso and sevo provide some analgesic effect for a while after emergence, owing to their slower off gassing from tissue depots, giving PACU RNs time to give some opioids. But des is gone fast. I see a lot of people underdose intraop opioids when using des, basically doing the same thing that works with iso/sevo, and then the wild kids and adults in PACU are having "emergence delirium".
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I'm not saying opioids limit nausea and delirium, but that using opioids supplements the primary anesthetics a bit, allowing less of them to be used. Less volatile gas leads to less nausea, delirium, and quicker wakeups in my experience.
If I really want to be minimal with my anesthesia, I use SedLine over BIS, as I find it's raw EEG waveforms better and it presents the data over time as a density spectral array. It also sticks to the forehead better.
If I really want to be minimal with my anesthesia, I use SedLine over BIS, as I find it's raw EEG waveforms better and it presents the data over time as a density spectral array. It also sticks to the forehead better.
Regarding regional anesthesia and side effects. Fresh in print.
Anesthesiology
Explore Anesthesiology, featuring peer‑reviewed articles, clinical studies, and the latest medical research.
The older I get, the less opiate I administer. My goal is simple, I want wide awake patients in PACU who are free of pain and nausea. I listen to the PACU nurses who have a clue, and I'm convinced the #1 cause of PONV, and PACU sedation, is unnecessarily excessive opiate administration. For truly painful cases, there are local anesthetics, for everything else 100mcg of fentanyl is almost always more than enough. Ex-Laps get epidurals or TAP blocks. Orthopedic surgeries get blocks. I use more than 100 mcg of fentanyl, or add in hydromorphone, maybe once or twice per month.
I never use opiates for GI scopes.
I titrate based on EtCO2 at the end of the case. 40 for PSV, 50 for SV. Keep it simple.
Intraoperatively, judicious use of beta blockers is pretty effective.
I am just finishing up a bilateral knee replacement case. The isobaric spinal was sufficient, although I did add 25 mg of ketamine to my propofol for the last hour just in case. The patient is snoring comfortably as her exparel blocks set up.
My patients are happy, my PACU nurses are happy, my life is good. For the life of me, I can't figure out why I used to feel like I had to use higher fentanyl doses, and hydromorphone, so frequently.
I never use opiates for GI scopes.
I titrate based on EtCO2 at the end of the case. 40 for PSV, 50 for SV. Keep it simple.
Intraoperatively, judicious use of beta blockers is pretty effective.
I am just finishing up a bilateral knee replacement case. The isobaric spinal was sufficient, although I did add 25 mg of ketamine to my propofol for the last hour just in case. The patient is snoring comfortably as her exparel blocks set up.
My patients are happy, my PACU nurses are happy, my life is good. For the life of me, I can't figure out why I used to feel like I had to use higher fentanyl doses, and hydromorphone, so frequently.
And you can get the same results skiping the fentanyl altogether.
For the above poster my experience is the exact opposite: nausea in PACU is 0% volatile or N2O and 99% opiates.
As a trainee you generally act too fast and overcorrect. As you get older you let things ride out a little more.
Sypathetic output is not going to be overwhelming when you have a mac of gas and a plane block pre incision and if the BP goes to 160 and HR 100 it is self limited most of the time. If not, i like to use clonidine.
Also consider that if the patient is going to be placed in reverse Tberg after incision this is going to affect BP substancially.
As i said overall i find i'm correcting hypotension more ofte0n than hyperta.
I like to do as much of nothing as possible for a similar outcome.
Typical case for me is prop/trac intubate, turn on sevo 8% at 0.5L/min do TAP block w decadron reduce sevo around 4% give repeat NMB if slow surgery or weak batch, paracetamol nsaid at the end, nmb reversal zofran.
