Do we need narcotics in anesthesia?

[Noyac]

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Can you do a major (belly)case without narcotics? Can we get by with decadron, Mg, ketamine, clonidine, etc?
How many of you have done it?

Surgeon good with local?

Do you need regional?

What other meds can you use?

 

[echolab]

Not sure since I have never seen it done. A PCEA works wonders post-operatively though, even without the fentanyl.

 

[urge]

One of the pain attendings during residency used to say that you don't need narcotics during GA since you are not awake and cannot feel pain. We only gave them to make the vital signs look better.

Post op is another story.

 

[NICMAN]

I know Dr. James Griffith at UT-Southwestern is a big proponent of avoiding the use of narcotics for belly cases. I can't remember how he does it though--although I think it includes IV precedex and ketamine.

 

[BobBarker]

I haven't worked with him in 5 years but at the time he gave preop oral methadone, lidocaine infusion, and intranasal precedex. Worked great the few times I saw it. I had limited understanding of what he was trying to accomplish as a MS4 in July so I may have missed a few things.

 

[Planktonmd]

Can you do a major (belly)case without narcotics? Can we get by with decadron, Mg, ketamine, clonidine, etc?
How many of you have done it?

Surgeon good with local?

Do you need regional?

What other meds can you use?

Yes... you can:
Pre-op Acetaminophen and gabapentin, Intra-op Ketamine + Propofol infusion with muscle relaxant, inhaled agent can be added sometimes at a low concentration.
Give Magnesium intra-op and Decadron as well.

 

[sevoflurane]

You absolutely can. Why give narcotics when you have a great working epidural? 'Ol friend and regional mentor of mine used to say that you give a little narcotic for the neuraxial or PNB (tuhoy, stimuplex, etc). No reaseon for them intra-op if it's in the right place... and I agree.

More nausea, more vomiting, more itching, more delayed awakening, more ileus, dare I say more cancer (mu receptor+ cancers).

Funny... 4-5 years ago I used to give 1000-1500mcgs of fent for a pump run. Now days, it's like 100mcg of sufenta (or 250 of fent) before going on... and that is mainly for sternotomy.

Propofol, Ketamine, ketafol, Magnesium, IV tylenol, lyrica/gabapentin, precedex/clonidine/decadron/.5 mac volatile, etc... + a great regional = great anesthestic IMHO.

 

[kazuma]

I placed bilateral TAP catheters in a 95F for an ex-lap SBO a while ago. She was pretty Snowed on morphine preop and I'm sure they gave her some narcotics intraop but she didn't have a single MCG of narcotic for the rest of her post op course. We left the catheters in for about a week and she was A/Ox3 the entire time.

 

[Spinach Dip]

The most important time for the delivering of narcotics is immediately before the patient is removed from the vent.

At least, that's my personal experience.

 

[Noyac]

The most important time for the delivering of narcotics is immediately before the patient is removed from the vent.

At least, that's my personal experience.

True. What made me think of this was a case I did yesterday. It was a 4 hr ALIF and PSF I did with 150mcg of Fent. 100mcg for induction and intubation and 50 for emergence. No ketamine.

I frequently do cases without any narcs but I have some regional going. Either an epidural for an abdominal case or a block for Otho.

Anybody use beta blockers for pain?

 

[deleted171991]

One of the pain attendings during residency used to say that you don't need narcotics during GA since you are not awake and cannot feel pain. We only gave them to make the vital signs look better.

Post op is another story.

In what part of the country was this?

 

[Noyac]

One of the pain attendings during residency used to say that you don't need narcotics during GA since you are not awake and cannot feel pain. We only gave them to make the vital signs look better.

Post op is another story.

I don't believe this for one minute. This is not the reason I posted this thread.

 

[deleted171991]

Funny thing, I had an absolutely similar pain attending during residency.

Makes me wonder whether it's the same person, or just the same studies they both read.

 

[europeman]

How does magnesium help pain?

 

[deleted171991]

It seems to decrease NMDA.

 

[OB1🤙]

I think this is an interesting topic. I had a few attendings in residency that, because of literature at the time suggesting that intraop narcotics just might exacerbate long-term metastases, would completely avoid intraop narcotics during abdominal and breast cancer whacks. (First Google hit on this topic- http://www.uchospitals.edu/news/2012/20120321-opioid.html).

They'd get through the case with esmolol and nitro. At the end, during closure, would reverse and then titrate in narcs to respiratory rate.

I thought they were nuts at first. What about preemptive analgesia? Stress of surgery? Spinal cord wind-up? Surely they'd wake up miserable?

Nah. These patients all did just fine postop. Indistinguishable from pts having "usual" management with intraop narcs. I was pretty impressed. So I needed convincing, but I am in the camp that you don't need intraop narcotics. The patient doesn't have a functioning cortex, there is no "pain," which is a conscious experience. That said, it's usually easier to just give the narcs.

For the elderly or those with ADRs (i.e. nausea), I try to limit as much as possible, which is sometimes to zero. In fact just did a narc-free lap chole- pt with severe nausea to all narcs (but apparently not volatile). Induced with ketafol, made sure surgeons gave adequate local, IV tylenol and toradol at the end. Comfortable in PACU, no nausea.

I almost never give more than a total of 500mcg total fentanyl to my hearts, which is how much they would have had on board by skin incision during training. They (mostly) all get ketamine and magnesium, the elderly also get IV tylenol.

For elderly patients getting procedures that a block covers, I don't use narcs either.

I think at the end of the day, it behooves us to limit them to whatever amount is reasonable for that patient having that surgery. Every patient will be different.

 

[dhb]

Very rarely do i use more than 50mcg of sufenta over a day of cases.
Maybe 1 in 10 or less of my davinci cases receives 5mcg of sufenta the rest none with just TAP blocks. Laparotomies get TAPs and often don't need narcotics intra-op. Post-op pca will typically show 10mg of morphine used in the first 48h
Even for back cases like anterior fusions i'll give 2 or 3 times 4mcg of sufenta with 10mg of K over the course of the surgery.
If i have to do a very long case i'll use a sufenta infusion but at vey low dose 2-4mcg/h.
Is it because i limit narcotics to a minimum that i virtually have no ponv complaints in the pacu? maybe i don't do a lot of pre-treatment just a 5ht3 antagonist if there is a history of ponv or if clinically i feel like it's needed.
My partners are all much older than me and are surprised with this approach but haven't been able to complain about the results.

So do we need narcotics: clearly not.
Useful tool yes (i like to intubate with remi for short cases) probably overused because it's easier to give them than to add some form of regional to your GA

 

[BuzzPhreed]

At the ASA meeting last fall they were discussing the pain ladder and how we overuse narcotics. Probably right on the money. Regional anesthesia is a great solution. And ibuprofen and Tylenol is enough for those who can tolerate it.

The problem is this stupid notion that people should not suffer any pain after an operation that has crept into our practice over the past few decades. Again it's this "pain is the fifth vital sign" horse**** that's been promulgated by the Nursing Industry™ and is nothing short of complete garbage that we have to deal with every day. Pain is not a "sign". Asking a patient to rate their pain on a scale of 0 to 10 is idiotic. It's a subjective symptom. (You want a fifth vital sign? How about BMI?)

I blame the nursing agenda in no small part for the epidemic of prescription narcotic abuse in this country. This is what happens when you let people step outside of their area of knowledge and expertise and foster, support, and encourage a movement without fully understanding its ramifications. How many perfectly awake and comfortable patients have you dropped off in the PACU then return thirty minutes later to sign them out only to find them completely snowed?

 

[Planktonmd]

In the old days there were some puritans who advocated the use on only one agent for the entire anesthetic... it was not the most elegant technique... but it worked!

 

[BuzzPhreed]

In the old days there were some puritans who advocated the use on only one agent for the entire anesthetic... it was not the most elegant technique... but it worked!

Kind of like trying to play an entire round of golf with only your five iron. You'll finish. You might even score well if you're skilled. But you're leaving a whole lot of other good tools in the bag.

I'm all for balanced anesthesia. I'm not for a one size fits all approach. Each patient is unique. Anesthetics should be tailored. Everyone undergoing a particular case shouldn't automatically get the same anesthetic.

Now just try to convince my CRNA "colleagues" of that.

 

[deleted59964]

Can you do a major (belly)case without narcotics? Can we get by with decadron, Mg, ketamine, clonidine, etc?
How many of you have done it?

Surgeon good with local?

Do you need regional?

What other meds can you use?

Anesth Analg. 2007 Nov;105(5):1255-62, table of contents.
Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy.
Collard V1, Mistraletti G, Taqi A, Asenjo JF, Feldman LS, Fried GM, Carli F.
Author information

Abstract
BACKGROUND:
The use of opioids during ambulatory surgery can delay hospital discharge or cause unexpected hospital admission. Preliminary studies using an intraoperative continuous infusion of esmolol in place of an opioid have inconsistently reported a postoperative opioid-sparing effect. In this study, we compared esmolol versus either intermittent fentanyl or continuous remifentanil on postoperative opioid-sparing, side effects, and time of discharge.

METHODS:
Ninety patients (consisting of three groups) were enrolled in this prospective, randomized, and observer-blinded study. The control group (n = 30) received intermittent doses of fentanyl, the esmolol group (n = 30) received a continuous infusion of esmolol (5-15 microg x kg(-1) x min(-1)) and no supplemental opioids during surgery, and the remifentanil group (n = 30) received a continuous infusion of remifentanil (0.1-0.5 mixrog x kg(-1) x min(-1)). General anesthesia was standardized, and adjuvant medications included acetaminophen, ketorolac, local anesthetics in the skin incisions, dexamethasone, and droperidol. Postoperative analgesia included fentanyl.

RESULTS:
The amount of fentanyl in the postanesthesia care unit was significantly less in the esmolol group, 91.5 +/- 42.7 microg, compared with the other two groups, remifentanil, 237.8 +/- 54.7 microg, control, 168.1 +/- 96.8 microg (P < 0.0001). The incidence of nausea was more frequent in the control (66.7%) and remifentanil (67.9%) groups compared with the esmolol group (30%) (P < 0.01). The esmolol group reached the White-Song score of 12 of 14 faster than the remifentanil group (P < 0.01), and left the hospital 45-60 min earlier (P < 0.004).

CONCLUSIONS:
Intraoperative IV infusion of esmolol contributes to a significant decrease in postoperative administration of fentanyl and ondansetron and facilitates earlier discharge.

Comment in

• Non-opioid anesthesia with esmolol avoids opioid-induced hyperalgesia and reduces fentanyl requirement after laparoscopy. [Anesth Analg. 2009]

 

[Noyac]

Yes esmolol. Finally! Nice call jobsfan.

 

[BuzzPhreed]

Esmolol. Cute. Try explaining that one to a surgeon who can get a gallbladder out in 15 minutes.
"You're running a WHAT infusion on my patient?!??"

Damn French Canadians and their crazy ideas.

 

[dhb]

They don't talk about the amount of muscle relaxant used...

 

[deleted171991]

If I did a study like that, I would avoid any muscle relaxant, so I can pick up patient movement (since I cannot rely on HR/BP anymore).

 

[Noyac]

If you want some proof of how esmolol works use it on an awake pt in the recovery room who is in pain. It might surprise you.

 

[BuzzPhreed]

I don't doubt that it modulates pain. There has been a long discussed and interesting history with prototypical drugs like propranolol and pain perception by modifying the sympathetic nervous system where these drugs work.

I'm talking about "educating" (i.e pissing off) the surgeon if you try this stunt in private practice land. Might be a fun thing to try in residency, which is long over for some of us.

 

[Noyac]

You may be correct in many practices. However, I've been at my current gig for 10yrs and the surgeons I work with would not have an issue with this. Mostly, because I would not have a pt in pain just to prove a point. I'm not saying you can completely avoid narcs in all cases with it but you can greatly decrease the amount you need. And then when they need something later in either recovery or on the floor, the pt needs less to get the desired effect at times.

 

[BuzzPhreed]

So esmolol effect lasts longer than its 9 minute half life? Just curious.

 

[Noyac]

So esmolol effect lasts longer than its 9 minute half life? Just curious.

Well you know, I'm not sure. All I can say is, "it depends". In the PACU if a pt isn't improving much with narcotics then give some esmolol and watch it work. It can be impressive at times, not always but frequently it can.
In the OR, use it at times instead of maybe 50mcg of fentanyl and see what you think. It's most impressive for short stimulating moments.
Just tonight I had a sick as **** guy in pacu with penile pain 8/10 after a cysto, retrograde stent attempts and bladder irrigation through one of the largest foley cath's I've seen. Guy is inconsolable and has had his share of narcs. I had a meeting so I ordered 2gms Mg in 50 ML NS run wide open. Checked back in 45 minutes and nurses had already taken him to the floor. They said he instantly went to 0/10pain. They were shocked. I went to see him on the floor and he is snoring like a train cuz all the narcs are unopposed since he had no pain. Now, I wonder what esmolol would have done in this case. I doubt it would have been this impressive. I find Mg works best for this vague sort of pain, ie: uterine pain after ablation etc. I haven't found esmolols a niche except for brief intense pain I guess.

 

[deleted59964]

Esmolol. Cute. Try explaining that one to a surgeon who can get a gallbladder out in 15 minutes.
"You're running a WHAT infusion on my patient?!??"

Damn French Canadians and their crazy ideas.

i've only done it a few times - it works better than i thought it would - no patients in agony in recovery.
I only used my initial dose of ndmr for the tube.
i would recommend not explaining it to the surgeon

 

[Spinach Dip]

i would recommend not explaining it to the surgeon

"It works. Trust me."

*jedi hand waving*

 

[BuzzPhreed]

i would recommend not explaining it to the surgeon

Not that long ago I worked with a particular urologic surgeon who would look at the chart afterwards to see if you'd given anyone pressors during the cases. Any pressors, even 40mcg of phenylephrine. If he saw that you gave more than he thought should have been given he would come and ask you about it. If you needed a touch of vaso or something, watch out. If he didn't like the answer he was known to submit it for peer review.

Some urologists hang around dicks for so long that they eventually turn into one.

 

[dhb]

I've tried the Mg trick a couple of times (per Noy's past experience) and it does work, but are you saying esmolol is effective in the pacu as a rescue pain treatment?

 

[Noyac]

I've tried the Mg trick a couple of times (per Noy's past experience) and it does work, but are you saying esmolol is effective in the pacu as a rescue pain treatment?

Yes

 

[sevoflurane]

Magnesium is da bomb as a multimodal agent. Such a great profile and synergistic with ketamine and propofol and therefore ketafol.
I'm in the 4 gm camp.

 

[stonemd]

I would suggest we do not use the term 'narcotic'. It can mean:
Any psychoactive compound,
An opiate
An prohibited medication

We are discussion avoiding 'opioids' in anesthesia, and should use that more precise term.

 

[BuzzPhreed]

😆 Yessir!

Actually it comes from the Greek root "narko-" meaning numbing. But that's just further splitting hairs, isn't it?

 

[Dwindlin]

I would suggest we do not use the term 'narcotic'. It can mean:
Any psychoactive compound,
An opiate
An prohibited medication

We are discussion avoiding 'opioids' in anesthesia, and should use that more precise term.

Is this real life?

 

[Precedex]

I think patients do better with a primarily opioid based anesthetic. 5-10 mcg/kg fentanyl with induction plus some morphine/dilaudid up front for just about anything longer than an hour with controlled vent. The benefit is hemodynamic stability and the ability to use much less gas. I find this techniques leads to faster wakeups, happier patients and PACU nurses, and less ponv.

 

[Noyac]

I think patients do better with a primarily opioid based anesthetic. 5-10 mcg/kg fentanyl with induction plus some morphine/dilaudid up front for just about anything longer than an hour with controlled vent. The benefit is hemodynamic stability and the ability to use much less gas. I find this techniques leads to faster wakeups, happier patients and PACU nurses, and less ponv.

Seriously?

 

[BuzzPhreed]

I have to agree. 5-10 mcg/kg of fentanyl? So you give a 70 kg man up to 700 mcg of fentanyl for a 20 minute case? We're not talking about sawing a cardiac cripple's sternum here.

 

[deleted59964]

Not that long ago I worked with a particular urologic surgeon who would look at the chart afterwards to see if you'd given anyone pressors during the cases. Any pressors, even 40mcg of phenylephrine. If he saw that you gave more than he thought should have been given he would come and ask you about it. If you needed a touch of vaso or something, watch out. If he didn't like the answer he was known to submit it for peer review.

Some urologists hang around dicks for so long that they eventually turn into one.

i don't know what to say to that - that doesn't happen here.

 

[pgg]

I have to agree. 5-10 mcg/kg of fentanyl? So you give a 70 kg man up to 700 mcg of fentanyl for a 20 minute case? We're not talking about sawing a cardiac cripple's sternum here.

Well he did say > 1 hr with controlled ventilation. Still, that's a ton of opiate. I don't think I'll try it.

 

[pgg]

Not that long ago I worked with a particular urologic surgeon who would look at the chart afterwards to see if you'd given anyone pressors during the cases. Any pressors, even 40mcg of phenylephrine. If he saw that you gave more than he thought should have been given he would come and ask you about it. If you needed a touch of vaso or something, watch out. If he didn't like the answer he was known to submit it for peer review.

You could've had some fun with that.

Just chart his real blood loss instead of the "5 cc" surgeons like to report, and submit his bloodletting butchery for peer review.

The best D-fense is a good O-fense. You know who said that?

 

[BuzzPhreed]

You could've had some fun with that.

Just chart his real blood loss instead of the "5 cc" surgeons like to report, and submit his bloodletting butchery for peer review.

The best D-fense is a good O-fense. You know who said that?

Haha. Yeah. This guy was a real tool. People were afraid to work with him. And administration never backed the anesthesia department. Go figure. I even saved a case of his from being cancelled and do you think I even got a thank you?

 

[Precedex]

I have to agree. 5-10 mcg/kg of fentanyl? So you give a 70 kg man up to 700 mcg of fentanyl for a 20 minute case? We're not talking about sawing a cardiac cripple's sternum here.

No but for 2 hour case yes.

 

[Noyac]

I haven't given that much fentanyl to a pt in a very long time. I do some long spine cases, albeit in pp were they are considered long at 4 hrs, and ALL my pts wake up extremely comfortable.

Basically, the more "opiates" you give intra-op the more they will need post-op.

 

[sevoflurane]

There are better ways to do a 2 hour case than with 700 mcg of fent. The caviat would be the ones that require more... and your experience will determine how much more to give. Titrating up on opiods is not the way IMHO. Opiod sparing analgesics are the way to go in these cases.

 

[OB1🤙]

Kinda tangential but anybody using methadone out there? Had a few who used it in residency and I liked what it got you- nice smooth profile, some NMDA antagonism, and long duration. None of my current shops have it IV unfortunately. Would be nice for big cases- back whacks, etc.