Dilaudid vs Fentanyl

[deleted875186]

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.

I love it, exactly what I do, except I will say I prefer a small dose of hydromorphone at the end of surgery rather than a TAP. TAP blocks are annoying to me and frequently disappointing, maybe I don’t do them perfect though.

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[Drwine]

We should have a plan for postop pain. When I first started in the 1980s narcotics were the mainstay for patients that had general anesthesia. With the advent of ultrasound, nerve blocks and other field blocks have taken off exponentially and minimally invasive surgery is much more prevalent. Patients that receive hydromorphone intraoperatively or in the recovery room in the "slow checkout lane" which isn't a big deal for a major operation with planned hospitalization. For those where we are planning other ways to manage pain it does slow everything down. Three years ago I had a robotic surgery and only made one request of my colleague which was to not give me Dilaudid but to make it available if I asked the recovery room nurse for it. Needless to say the TAP blocks and ketorolac along with ice packs were enough and I never took any narcotic perioperatively. I was up and walking around the hospital floor shortly after surgery and my recovery was very rapid. I had to send the recovery nurses to get me more ice every time they suggested that maybe I should just get some Dilaudid. Same thing on the floor.

 

[zizzer]

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.

Well, based on your description of titrating opioids to EtCO2 of 50, it seems like you're waking people up from surgery with a decent effect-site concentration of opioids. Excess of opioids and volatile agents each can cause nausea. I'm guessing how we practice isn't that much different (avoiding excess volatile agent with judicious opioid use).

I guess we're attributing others' patients' PONV to different causes though. I notice a lot of people tend to run levels at 1.0 MAC or higher even with neuromuscular blockade for the entire case for no apparent reason. This is going to be diffusing out of the adipose tissue while in PACU for a while and seems to make people feel like ****. I'm sure others overdo the opioids and cause PONV as well, but I just don't seem to see it as commonly.

 

[Hoya11]

We should have a plan for postop pain. When I first started in the 1980s narcotics were the mainstay for patients that had general anesthesia. With the advent of ultrasound, nerve blocks and other field blocks have taken off exponentially and minimally invasive surgery is much more prevalent. Patients that receive hydromorphone intraoperatively or in the recovery room in the "slow checkout lane" which isn't a big deal for a major operation with planned hospitalization. For those where we are planning other ways to manage pain it does slow everything down. Three years ago I had a robotic surgery and only made one request of my colleague which was to not give me Dilaudid but to make it available if I asked the recovery room nurse for it. Needless to say the TAP blocks and ketorolac along with ice packs were enough and I never took any narcotic perioperatively. I was up and walking around the hospital floor shortly after surgery and my recovery was very rapid. I had to send the recovery nurses to get me more ice every time they suggested that maybe I should just get some Dilaudid. Same thing on the floor.

lol .. cool story bro.. but give me the dilaudid! did you receive a trophy for no dilaudid? this conversation is scary... opiates are a good part of a balanced anesthetic

100 of fentanyl is not going to slow anyone down or cause any side effects and smooths out the anesthetic even if its for a non painful case like carpal tunnel. i work in a very high turnover place and unless they are very old they get 100 of fent and very rarely any problems, happy patients and nurses

 

[2Fast2Des]

I was total anti opioid and all multimodal in residency and early into practice. Then I started to use opioids again and I notice how it does smooth out anesthetics and patients can wake up a lot better. That being said, there are cases that don't need it or minimal, and 100mcg fentanyl divided through a case can go a long way. Even for simple MAC cases a little 25mcg can make for a smoother experience, and especially for the EGD on morbid obese people really makes it a lot easier allowing less prop use.

That being said, good use of local and\or functional block is necessary as well to facilitate all the above. Ketamine and precedex etc have their place but I've stopped blanket use of it as I've learned like the experienced peeps that at the end of the day patient will get their Dilaudid eventually so what is the point of delaying discharge from recovery when you can get them primed in the OR comfortable. When I was using precedex a lot patients there was more incidence of bradycardia\hypotension\drowsiness in PACU and with ketamine even 0.5mg\kg dose would cause patients to have sensation of dizziness and such. When I cut back I've noticed patients feel more alert and ready to hit the road sooner, especially at the ASCs where they need to be out the door ASAP. Esmolol works great to shut down that sympathetic surge and I've seen many times one dose gets them back to normal HR for the remainder of the case without having to redose. Reserve the opioid but use it wisely. That's My 2cents

 

[deleted875186]

lol .. cool story bro.. but give me the dilaudid! did you receive a trophy for no dilaudid? this conversation is scary... opiates are a good part of a balanced anesthetic

100 of fentanyl is not going to slow anyone down or cause any side effects and smooths out the anesthetic even if its for a non painful case like carpal tunnel. i work in a very high turnover place and unless they are very old they get 100 of fent and very rarely any problems, happy patients and nurses

I would have to agree. The more important point is you were a reasonable patient, expected some degree of postop pain no matter what. I would say a few doses of hydromorphone probably would not have harmed you in any way.

 

[Drwine]

I would have to agree. The more important point is you were a reasonable patient, expected some degree of postop pain no matter what. I would say a few doses of hydromorphone probably would not have harmed you in any way.

Agreed but I most likely wouldn't have been able to ambulate as much early. I am not against fentanyl to smooth out induction and emergence but the visual analogue pain scale has resulted in over treating pain and more than minimal narcotics put the patient in the "slow checkout lane" as opposed to the express checkout lane.

 

[Mike1228]

View attachment 341738

1) Nope, not a Nurse
2) You're showing everyone that you are not too sharp. Ketamine and Precedex are great drugs WHEN USED PROPERLY (Especially ketamine). When looking at flowcharts of cases performed by CRNAs, many have used ketamine for initial incision pain which is actually WAY more effective than opioids to block that initial incisional somatic pain ans then using opioids for the rest of the cases visceral pain.
Precedex definitely has a place and is an excellent tool if used correctly. Intraop when you're trying to control hemodynamics and SS response, Precedex can 100% replace Dilaudid. Not replace it on an awake patient just a deep anesthetized pt.
Titration opioids to RR on emergence. Of course breathing off the gas is going to cause fast RR and shallow TV regardless but giving opioids based on RR is not only covering postop pain but also tolerance to the ETT and leading to an ultra smoothe extubation. Im talking only 25-50 mcg can have a world of difference. Some of you guys have little to no experience and just throw the word "crna drugs" or "crna tactics" around because maybe your were wronged somehow, idk. Opioids are definitely needed and should never be pushed out, BUT there is zero doubt we can decrease them without effecting patient outcomes. I just did a big multilevel spine and only used 100 mcg of fentanyl and 0.5 mg of Dilaudid. I did this because I also used ketamine, lidocaine drip, and Robaxin. Use your brain, don't limit yourself to opioids and gas hahaha.

 

[vector2]

1) Nope, not a Nurse
2) You're showing everyone that you are not too sharp. Ketamine and Precedex are great drugs WHEN USED PROPERLY (Especially ketamine). When looking at flowcharts of cases performed by CRNAs, many have used ketamine for initial incision pain which is actually WAY more effective than opioids to block that initial incisional somatic pain ans then using opioids for the rest of the cases visceral pain.
Precedex definitely has a place and is an excellent tool if used correctly. Intraop when you're trying to control hemodynamics and SS response, Precedex can 100% replace Dilaudid. Not replace it on an awake patient just a deep anesthetized pt.
Titration opioids to RR on emergence. Of course breathing off the gas is going to cause fast RR and shallow TV regardless but giving opioids based on RR is not only covering postop pain but also tolerance to the ETT and leading to an ultra smoothe extubation. Im talking only 25-50 mcg can have a world of difference. Some of you fguys have little to no experience and just throw the word "crna drugs" or "crna tactics" around because maybe your were wronged somehow, idk. Opioids are definitely needed and should never be pushed out, BUT there is zero doubt we can decrease them without effecting patient outcomes. I just did a big multilevel spine and only used 100 mcg of fentanyl and 0.5 mg of Dilaudid. I did this because I also used ketamine, lidocaine drip, and Robaxin. Use your brain, don't limit yourself to opioids and gas hahaha.

Lol “Precedex can 100% replace Dilaudid.”

Sure thing, nurse (it’s telling that there were three full pages of interesting discussion since you last posted, but the post you ended up replying to was the meme trolling crnas). Anyway, I bet you’re probably one of those nurses who boluses 30 mcg of precedex if an 80 yo gets a little tachycardia during a 1hr cysto and then proceeds to wonder why the wakeup is taking so long.

 

[Mike1228]

Lol “Precedex can 100% replace Dilaudid.”

Sure thing, nurse (it’s telling that there were three full pages of interesting discussion since you last posted, but the post you ended up replying to was the meme trolling crnas). Anyway, I bet you’re probably one of those nurses who boluses 30 mcg of precedex if an 80 yo gets a little tachycardia during a 1hr cysto and then proceeds to wonder why the wakeup is taking so long.

Haha or because that was a post directed at me personally. Dude, you got issues 🤣

 

[deleted875186]

I personally don’t care for precedex. I think in most GA cases it doesn’t really have a role. Maybe in a TIVA recipe it’s helpful. I never use it for sedation because You always need to add other hypnotic/opioids etc to get anything more than mild sedation with it.

 

[vector2]

Haha or because that was a post directed at me personally. Dude, you got issues 🤣

Well, I didn’t even quote you directly and the graph was relevant to the discussion 10 other people were having, so again, it’s obvious you’re a nurse by how personally you happened to take it.

And indeed, I do have issues. One of my biggest issues is having to reiterate over and over and over to nurses that not every case (not even every moderately painful one) needs boluses of precedex and ketamine to achieve satisfactory hemodynamics and/or analgesia, but it’s lost on many of them because nurses don’t have to deal with post-operative issues in the PACU like delayed emergence, prolonged sympathectomy causing hypotension, delirium from accidental near-dissociative total intraop ketamine doses, and prolonged time to discharge.

 

[robellis]

I noticed the OP has been noticeably silent after that nurse anesthetist comment…

 

[coffeebythelake]

I noticed the OP has been noticeably silent after that nurse anesthetist comment…

I agree w vector. At first the OP read like a newbie trainee seeking feedback and knowledge (something that we wholeheartedly support)...

but the more he writes the more it appears he is a CRNA who knows just enough to be arrogant and dangerous. This whole discussion thread has been about merits of different techniques, pros and cons of different drugs, our own approaches to acute pain management. Hopefully everyone learned a bit and gained a bit from the formative discussion. Meanwhile the OP basically says "don't care, this is my way and I'm right"

 

[Arch Guillotti]

I noticed the OP has been noticeably silent after that nurse anesthetist comment…

Yep.

 

[Mike1228]

I agree w vector. At first the OP read like a newbie trainee seeking feedback and knowledge (something that we wholeheartedly support)...

but the more he writes the more it appears he is a CRNA who knows just enough to be arrogant and dangerous. This whole discussion thread has been about merits of different techniques, pros and cons of different drugs, our own approaches to acute pain management. Hopefully everyone learned a bit and gained a bit from the formative discussion. Meanwhile the OP basically says "don't care, this is my way and I'm right"

I actually read thru and thoroughly enjoyed everyone else's comments and I made the post because I was curious about everyone's opinions. Then, out of no where Vector and another initial post (forget the name and d5int care to look back) didn't offer any advice and only offered accusations and insults for no reason. Look back over the whole convo....so I responded to the accusation simply. Also, I don't spend all day on this thread so I've reading and enjoying the posts until I got to the inappropriate couple posts directed at me for no reason lol. No reason to respond to everyones post when they make good points, I'd rather think about it and take them into consideration. Accusations require a response....I used to enjoy reading from the forum but I realize that this site has become more and more hostile and opionated.
....but hey whatever, I can see that those that seek questions and advice are not welcome here and are only harnessed by people with nothing of value to offer. Thank you to everyone else that did offer value to this thread.

 

[robellis]

I actually read thru and thoroughly enjoyed everyone else's comments and I made the post because I was curious about everyone's opinions. Then, out of no where Vector and another initial post (forget the name and d5int care to look back) didn't offer any advice and only offered accusations and insults for no reason. Look back over the whole convo....so I responded to the accusation simply. Also, I don't spend all day on this thread so I've reading and enjoying the posts until I got to the inappropriate couple posts directed at me for no reason lol. No reason to respond to everyones post when they make good points, I'd rather think about it and take them into consideration. Accusations require a response....I used to enjoy reading from the forum but I realize that this site has become more and more hostile and opionated.
....but hey whatever, I can see that those that seek questions and advice are not welcome here and are only harnessed by people with nothing of value to offer. Thank you to everyone else that did offer value to this thread.

So what is your background I noticed you never mentioned it

 

[IMGASMD]

So what is your background I noticed you never mentioned it

Someone not a md/do. I’d be surprised if he would answer straightforwardly.

 

[Arch Guillotti]

I actually read thru and thoroughly enjoyed everyone else's comments and I made the post because I was curious about everyone's opinions. Then, out of no where Vector and another initial post (forget the name and d5int care to look back) didn't offer any advice and only offered accusations and insults for no reason. Look back over the whole convo....so I responded to the accusation simply. Also, I don't spend all day on this thread so I've reading and enjoying the posts until I got to the inappropriate couple posts directed at me for no reason lol. No reason to respond to everyones post when they make good points, I'd rather think about it and take them into consideration. Accusations require a response....I used to enjoy reading from the forum but I realize that this site has become more and more hostile and opionated.
....but hey whatever, I can see that those that seek questions and advice are not welcome here and are only harnessed by people with nothing of value to offer. Thank you to everyone else that did offer value to this thread.

Are you a physician or one in training?

 

[vector2]

Look at one of his previous posts:

“Quick question about giving fentanyl through an epidural and the effect on the delivered baby.
Many providers giving 100 mcg fentanyl down the epidural when laboring mom is at or close to 10 cm and close to delivering since those sacral nerves are tough to cover (even tho I find siting them up and giving 5-10ml of 1% lido helps a lot).”

How often you see resident or attending anesthesiologists using the term “provider” ?


Also lmfao at topping off an epidural with 10cc of 1% lido.

 

[GassYous]

So what is your background I noticed you never mentioned it

"mike with anesthesia"

 

[coffeebythelake]

....but hey whatever, I can see that those that seek questions and advice are not welcome here and are only harnessed by people with nothing of value to offer. Thank you to everyone else that did offer value to this thread.

You are not here to seek questions and advice. You are here to pretend to know something, and even though you post anonymously it is clear you are not a physician or an anesthesiologist. Your whole thought process (or at least the way you convey ideas) is black and white. Protocol driven.

Your words:
"You're showing everyone that you are not too sharp."
"Some of you guys have little to no experience"
"Use your brain, don't limit yourself to opioids and gas hahaha."

Your explanations are nonsensical. For instance, you wrote that precedex can 100% replace dilaudid, but actually it can't, only in deeply anesthetized patients. in other words it doesn't.

Read your own post and reflect.

 

[DrOwnage]

Back one day when I was the PACU resident, the record for the longest patient to ever wake up was a healthy person under GA who got 1 mcg/kg of precedex prior to emergence from general. They literally sat there for almost 3 hours with the oral airway in their mouth no joke.

 

[nimbus]

Back one day when I was the PACU resident, the record for the longest patient to ever wake up was a healthy person under GA who got 1 mcg/kg of precedex prior to emergence from general. They literally sat there for almost 3 hours with the oral airway in their mouth no joke.

Ive had a similar experience. Some people sleep for a very long time when they get precedex, but they don’t complain of pain or nausea..lol.

 

[IMGASMD]

"mike with anesthesia"

Mike be proud of what you are. If you’re a nurse, say it proudly. If you’re a doctor of nursing practice, say it loudly. Anesthesiologists assistant, that’s fine too.

What I cannot comprehend is some of these people, maybe you included, feel that they deserve to practice independently. But when people ask about their title, they’re ashamed to give their own job title. Hiding behind “nurse anesthesiologists” or “physician associates”. What a pile of doo doo.

I will now go back and re-read some of these different techniques or ways of doing my cases…. Received dirty looks when I was able to titration 2 of dilaudid for a simple chole.

 

[coffeebythelake]

Ive had a similar experience. Some people sleep for a very long time when they get precedex, but they don’t complain of pain or nausea..lol.

you mean when they are zonked out they don't complain?

 

[nimbus]

you mean when they are zonked out they don't complain?

yep