anbuitachi

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Does anyone here do or tried esmolol infusion instead of fentanyl? I remember there was a discussion in the past on this forum but I couldn't find it. I saw a few papers on the topic
 

Mman

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Does anyone here do or tried esmolol infusion instead of fentanyl? I remember there was a discussion in the past on this forum but I couldn't find it. I saw a few papers on the topic
No but I have been curious about it for some time. I believe that all narcotics cause hyperalgesia to some extent, the more rapid they go away the worse the effect. And while we have patients anesthetized under GA we claim to give narcotics for pain, but the patients are not subjectively experiencing that sensation at the time. We are really just doing it as part of a balanced anesthetic technique to decrease the amount of other things we are giving as well as trying to get some on board for their emergence when they will be experiencing some pain.

My best guess is that patients would use less narcotics and have less pain postoperatively if we gave less/none intraoperatively, saving them for the emergence when they begin to experience pain which is where esmolol drips might come in handy intraoperatively. Just paralyze them, run them deep on gas, and use esmolol drip for hemodynamics as needed and then give them narcotics when they are waking up.

but no I haven't actually used that on a patient yet
 
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dhb

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I use a fair amount of esmolol, sometimes metoprolol, for the specific purpose of minimizing opiates (and perhaps opioid induced hyperalgesia), but I've never run an infusion of it.
I just use clonidine
 

Newtwo

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Yeah I've done it a good few times for lap choles, younger more healthy ones
Works out great.
They're tachy from the co2 pneumo not pain, and they get plenty of local at the end
 
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Hoya11

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No but I have been curious about it for some time. I believe that all narcotics cause hyperalgesia to some extent, the more rapid they go away the worse the effect. And while we have patients anesthetized under GA we claim to give narcotics for pain, but the patients are not subjectively experiencing that sensation at the time. We are really just doing it as part of a balanced anesthetic technique to decrease the amount of other things we are giving as well as trying to get some on board for their emergence when they will be experiencing some pain.

My best guess is that patients would use less narcotics and have less pain postoperatively if we gave less/none intraoperatively, saving them for the emergence when they begin to experience pain which is where esmolol drips might come in handy intraoperatively. Just paralyze them, run them deep on gas, and use esmolol drip for hemodynamics as needed and then give them narcotics when they are waking up.

but no I haven't actually used that on a patient yet
You can not just let pain run rampant in the CNS..

You believe that your 100-200 of fentanyl boluses throughout the case in the face of surgical incision/pain is causing hyperalgesia.. do you have any evidence of that?

usually.. opioid induced hyperalgesia is thought of as developing as an adjustment of the nociceptor system through chronic opioid use over weeks/months/years

And to follow that logic, that therefore the people who you are giving this fentanyl to would have less pain if you just had not given the fentanyl you gave just minutes earlier ( and "sensitized" their receptors)?

What if there is no "sensitization" phenomenon and you are just depriving them of the neeed opioids? only to underdose them at the end after the pain has spun and spun untreated/uncontrolled in the CNS

What are the effects of chronic pain? delirium, depression, suicide, PTSD - its not just hypertension and tachycardia..

Nociceptor pathways are still being studied, but there is plenty of evidence to tell you that these pain signals are setting off alarms deep in the limbic system of the brain, not just autonomic responses..

To complicate the matter, I do believe beta blockers themselves may be helpful and block pain signals to some degree...

But the idea of "the person is asleep you dont need to treat there pain" I do not agree with..

You are seeing the hypertension and tachycardia as part of a constellation of CNS badness that is happening and that needs to be blocked
 

anbuitachi

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You can not just let pain run rampant in the CNS..

You believe that your 100-200 of fentanyl boluses throughout the case in the face of surgical incision/pain is causing hyperalgesia.. do you have any evidence of that?

usually.. opioid induced hyperalgesia is thought of as developing as an adjustment of the nociceptor system through chronic opioid use over weeks/months/years

And to follow that logic, that therefore the people who you are giving this fentanyl to would have less pain if you just had not given the fentanyl you gave just minutes earlier ( and "sensitized" their receptors)?

What if there is no "sensitization" phenomenon and you are just depriving them of the neeed opioids? only to underdose them at the end after the pain has spun and spun untreated/uncontrolled in the CNS

What are the effects of chronic pain? delirium, depression, suicide, PTSD - its not just hypertension and tachycardia..

Nociceptor pathways are still being studied, but there is plenty of evidence to tell you that these pain signals are setting off alarms deep in the limbic system of the brain, not just autonomic responses..

To complicate the matter, I do believe beta blockers themselves may be helpful and block pain signals to some degree...

But the idea of "the person is asleep you dont need to treat there pain" I do not agree with..

is the evidence of "hypealgesia" so strong that you would actually deprive people opiate
i was referring to intraop esmolol infusion, not denying patient pain meds throughout entire hospital stay. i would hardly call that chronic pain. chronic opioid use afterwards can lead to addiction, suicide and the sorts as well.
obviously dont treat the patients pain with esmolol postop.
like you mentioned, there was a studying showing esmolol use actually decrease postop narcotic use. supposedly because esmolol helps with pain control through beta blockade. (i didn't analyze the study though)
there are papers showing high opioid use intraop leads to increased post op opioid use in hospital stay (again didn't analyze these studies)

i am not sure about the opioid induced hyperalgesia part, but i do know remi induced hyperalgesia is real and many of them are not chronic opioid usage.
And lastly pain involves many pathways. fentanyl helps with one of them. unclear as to how big of an effect that has down the line in terms of outcome.

I was thinking of doing esmolol infusion intraop, and finishing off the case with a little bit of pain meds, or a regional block.
 

Hoya11

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i was referring to intraop esmolol infusion, not denying patient pain meds throughout entire hospital stay. i would hardly call that chronic pain. chronic opioid use afterwards can lead to addiction, suicide and the sorts as well.
obviously dont treat the patients pain with esmolol postop.
like you mentioned, there was a studying showing esmolol use actually decrease postop narcotic use. supposedly because esmolol helps with pain control through beta blockade. (i didn't analyze the study though)
there are papers showing high opioid use intraop leads to increased post op opioid use in hospital stay (again didn't analyze these studies)

i am not sure about the opioid induced hyperalgesia part, but i do know remi induced hyperalgesia is real and many of them are not chronic opioid usage.
And lastly pain involves many pathways. fentanyl helps with one of them. unclear as to how big of an effect that has down the line in terms of outcome.

I was thinking of doing esmolol infusion intraop, and finishing off the case with a little bit of pain meds, or a regional block.
im talking about intra op as well, im pointing out that if you subscribe to this idea you are proposing, that you are letting those deeper pain pathways/signals run rampant while the person is asleep while treating the htn and tachycardia, and what are the consquences of that? are they worth not giving the opiate?
 

Mman

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You can not just let pain run rampant in the CNS..



But the idea of "the person is asleep you dont need to treat there pain" I do not agree with..

You are seeing the hypertension and tachycardia as part of a constellation of CNS badness that is happening and that needs to be blocked

Honest question: then why are there studies showing less postoperative pain in patients that got less (or no) narcotics intraop compared to standard therapy?
 

dhb

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Honest question: then why are there studies showing less postoperative pain in patients that got less (or no) narcotics intraop compared to standard therapy?
Because when you give potent opioids you saturate the patient receptors and upon wake up the patient describing a painful sensation will be given morphine that has then less receptors available to act.
Imho this is what people call hyperalgesia (which i think is dumb) it's just a matter of receptor availability and function.
The other problem is that pain isn't accepted as a normal part of the act of undergoing surgery; why are we treating a 4 out of 10 "pain" which should reasonably be qualified as discomfort with opiods? Do we take morphine at home when we have 4/10 headache pain?

Expectations have shifted way to much towards a 0 pain & 100% recovery on day of surgery.

You know what cause chronic pain? A steel blade and a weak mind. Anesthesia doesn't cause chronic pain surgery does. Now if you're really bad at gas you're not going to make things better but all the mental masturbation going on about how we are going to make or break the patients future life experience with this drug or that one is a big pile of Sht.

/end rant +pissed+
 
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Laryngophed

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You can not just let pain run rampant in the CNS..

You believe that your 100-200 of fentanyl boluses throughout the case in the face of surgical incision/pain is causing hyperalgesia.. do you have any evidence of that?

usually.. opioid induced hyperalgesia is thought of as developing as an adjustment of the nociceptor system through chronic opioid use over weeks/months/years

And to follow that logic, that therefore the people who you are giving this fentanyl to would have less pain if you just had not given the fentanyl you gave just minutes earlier ( and "sensitized" their receptors)?

What if there is no "sensitization" phenomenon and you are just depriving them of the neeed opioids? only to underdose them at the end after the pain has spun and spun untreated/uncontrolled in the CNS

What are the effects of chronic pain? delirium, depression, suicide, PTSD - its not just hypertension and tachycardia..

Nociceptor pathways are still being studied, but there is plenty of evidence to tell you that these pain signals are setting off alarms deep in the limbic system of the brain, not just autonomic responses..

To complicate the matter, I do believe beta blockers themselves may be helpful and block pain signals to some degree...

But the idea of "the person is asleep you dont need to treat there pain" I do not agree with..

You are seeing the hypertension and tachycardia as part of a constellation of CNS badness that is happening and that needs to be blocked
Just to be pedantic, how can someone who is asleep have pain? Pain is a subjective experience that requires consciousness to experience.
 

Mman

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Because when you give potent opioids you saturate the patient receptors and upon wake up the patient describing a painful sensation will be given morphine that has then less receptors available to act.
Imho this is what people call hyperalgesia (which i think is dumb) it's just a matter of receptor availability and function.
The other problem is that pain isn't accepted as a normal part of the act of undergoing surgery; why are we treating a 4 out of 10 "pain" which should reasonably be qualified as discomfort with opiods? Do we take morphine at home when we have 4/10 headache pain?

Expectations have shifted way to much towards a 0 pain & 100% recovery on day of surgery.

You know what cause chronic pain? A steel blade and a weak mind. Anesthesia doesn't cause chronic pain surgery does. Now if you're really bad at gas you're not going to make things better but all the mental masturbation going on about how we are going to make or break the patients future life experience with this drug or that one is a big pile of Sht.

/end rant +pissed+

I believe pain is a protective reflex for us and when we give meds to blunt that response while the patient is unconscious, pathways get upregulated that enhance the pain response after the surgery is over and then require subsequently higher doses to achieve the same effect in the postop period.

But that's just an educated opinion. I'm not saying it's fact.
 

Mman

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I think that's a fancy way of saying a molecule is bound to a receptor rendering it unavailable to further stimulation.
it's also a fancy way of saying giving more narcotics intraoperatively makes the patient have worse pain postoperatively
 
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You’re not just trying to prevent tachycardia and hypertension , you’re trying to prevent the entirety of the sympathetic response. it’s just that the tachycardia is the most in your face component of the response that you can see and measure.

The real question is: do you believe that silencing the entirety of the sympathetic response is beneficial in any way. I believe that it is. I feel that there’s a definite difference in post op pain between those that get spinals that cover their procedure, and those that don’t get spinals. I think preventing the CNS “windup” , as it’s called, is a real thing
 
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dhb

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I feel that there’s a definite difference in post op pain between those that get spinals that cover their procedure, and those that don’t get spinals. I think preventing the CNS “windup” , as it’s called, is a real thing
Well i've had both and the post op pain was no different. So no windup is not a real thing.
You can b..ch about a little pain or you can suck it up.

We do need more b..ches sucking it up
 

Hoya11

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Honest question: then why are there studies showing less postoperative pain in patients that got less (or no) narcotics intraop compared to standard therapy?
you can prove anything for a pain study and you cant believe them all

and if people are getting opiates they are probably having a more painful surgery and need more post op
if people arent getting any intra-op they are probably having a less painful surgery and need less post op

surgery isnt surgery isnt surgery, the same surgery with a different surgeon can have drastically different pain scores
 

Hoya11

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Just to be pedantic, how can someone who is asleep have pain? Pain is a subjective experience that requires consciousness to experience.
because that person wakes up and has a wound up system without treated pain, agree its a moot point if they stay asleep forever.

pain and suffering have known psychiatric and subconscious effects, just because you werent conscious while the pain signal was being transmitted/reinforced/going round and round, doesnt mean that nervous system isnt wound up/pathologic now
 

T-burglar

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Well i've had both and the post op pain was no different. So no windup is not a real thing.
You can b..ch about a little pain or you can suck it up.

We do need more b..ches sucking it up
You had the same surgery by the same surgeon, one with spinal and one without?
 

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One of my bosses uses esmolol infusions for a lot of laparoscopic procedures; certainly for every lap. chole.
TIVA + Esmolol.
Typically bolus of Fent/Alf + Propofol TCI TIVA induction --> Start esmolol infusion (0.5 mg/kg loading followed by an infusion of 0.05 mg/kg/min - titrate to effect)
Stop the esmolol, give a loading dose of fent and T/F to recovery.
This activity has not been internally audited to see if there is actually a reduction in the amount of opioids given in recovery/post-op.
 

dipriMAN

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I was under the impression the theory of wind up has never been proven, many think it is not true. Does anyone have any actual evidence or read anything to prove/refute it?
 
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dipriMAN

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Because when you give potent opioids you saturate the patient receptors and upon wake up the patient describing a painful sensation will be given morphine that has then less receptors available to act.
Imho this is what people call hyperalgesia (which i think is dumb) it's just a matter of receptor availability and function.
The other problem is that pain isn't accepted as a normal part of the act of undergoing surgery; why are we treating a 4 out of 10 "pain" which should reasonably be qualified as discomfort with opiods? Do we take morphine at home when we have 4/10 headache pain?

Expectations have shifted way to much towards a 0 pain & 100% recovery on day of surgery.

You know what cause chronic pain? A steel blade and a weak mind. Anesthesia doesn't cause chronic pain surgery does. Now if you're really bad at gas you're not going to make things better but all the mental masturbation going on about how we are going to make or break the patients future life experience with this drug or that one is a big pile of Sht.

/end rant +pissed+
Someone can correct me if wrong, but this is not the proposed mechanism for opioid induced hyperalgesia. What your describing sounds more like tolerance, which clinically presents very similarly and is more common than hyperalgesia.
 

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One of my bosses uses esmolol infusions for a lot of laparoscopic procedures; certainly for every lap. chole.
TIVA + Esmolol.
Typically bolus of Fent/Alf + Propofol TCI TIVA induction --> Start esmolol infusion (0.5 mg/kg loading followed by an infusion of 0.05 mg/kg/min - titrate to effect)
Stop the esmolol, give a loading dose of fent and T/F to recovery.
This activity has not been internally audited to see if there is actually a reduction in the amount of opioids given in recovery/post-op.
Why not just give fentanyl throughout? Very strange
 

woopedazz

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Why not just give fentanyl throughout? Very strange
There's a few studies that reckon that "Intraoperative IV infusion of esmolol contributes to a significant decrease in postoperative administration of fentanyl and ondansetron and facilitates earlier discharge." I.e. less PONV if you use esmolol instead of fentanyl.

Our department is not sure if we believe it or not. A few attendings swear by the publications that support esmolol, a few attendings feel that the PACU opioid consumption is more/pain scores are more in the esmolol patients. We've yet to audit it.
 

anbuitachi

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One of my bosses uses esmolol infusions for a lot of laparoscopic procedures; certainly for every lap. chole.
TIVA + Esmolol.
Typically bolus of Fent/Alf + Propofol TCI TIVA induction --> Start esmolol infusion (0.5 mg/kg loading followed by an infusion of 0.05 mg/kg/min - titrate to effect)
Stop the esmolol, give a loading dose of fent and T/F to recovery.
This activity has not been internally audited to see if there is actually a reduction in the amount of opioids given in recovery/post-op.
not sure how much use this is for a lap chole, unless your boss' lap chole takes a long time. otherwise, bolus of fent/alf for induction, and another bolus to recovery, may have covered the patients pain intraop..

because that person wakes up and has a wound up system without treated pain, agree its a moot point if they stay asleep forever.

pain and suffering have known psychiatric and subconscious effects, just because you werent conscious while the pain signal was being transmitted/reinforced/going round and round, doesnt mean that nervous system isnt wound up/pathologic now
this is not exactly the same. obviously pain and suffering has known effects, but as far as i know, that's in a conscious person perceiving the pain. i dont know of any study comparing unconscious pain (probably cause pain is subjective) vs conscious pain. yes pain involves a lot of pathways but how much of the deep limbic system stuff is due to you being conscious and AWARE and FEELING the pain? That activates a lot more pathways than just cutting you when you are knocked out. Didn't they use chloroform/alcohol back in the day for surgery? Did they have opioids?

we all know as a country we use a ton of opioids, and i dont think our psych/neuro outcomes are better than other countries.
 

woopedazz

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not sure how much use this is for a lap chole, unless your boss' lap chole takes a long time. otherwise, bolus of fent/alf for induction, and another bolus to recovery, may have covered the patients pain intraop.
Teaching hospital with junior registrars and no attendings in OT --> They take a while.
 

Mman

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and if people are getting opiates they are probably having a more painful surgery and need more post op
if people arent getting any intra-op they are probably having a less painful surgery and need less post op

surgery isnt surgery isnt surgery, the same surgery with a different surgeon can have drastically different pain scores
Same surgeries by same surgeon.
 

vector2

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I don't have the literature handy but imo windup is a real thing. Time and time again I've noticed that pts who had pre incision local infiltrated or a spinal before incision had less pain postop even once the local had worn off. This is even more apparent when talking about surgeries like aka/bka where there's a significant neuropathic component.
 

anbuitachi

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I don't have the literature handy but imo windup is a real thing. Time and time again I've noticed that pts who had pre incision local infiltrated or a spinal before incision had less pain postop even once the local had worn off. This is even more apparent when talking about surgeries like aka/bka where there's a significant neuropathic component.
dont we also see this with regional block? thus the big uptick in ERAS protocols? just did a 7 hour abdominal case not that long ago, did a block at the beginning of the case. used zero narcotics, not for induction or emergence. the patients ended up using no narcotics long after block wore off.
 
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dont we also see this with regional block? thus the big uptick in ERAS protocols? just did a 7 hour abdominal case not that long ago, did a block at the beginning of the case. used zero narcotics, not for induction or emergence. the patients ended up using no narcotics long after block wore off.
Eh I've done blocks at the end of surgery with patient receiving no narcotics at all
 
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