high dose narcotic anesthesia

[bestiller]

(1) anybody have exp. w/ "high dose" fentanyl i.e. 12-15 mcgs/kg on induction, and narcotic of choice at end of case, agent run lower than norm. just wanted some different recipes....I've heard 2 people swear by this

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[Noyac]

Did that high dose thing (20-40 cc fentanyl for induction and about 60cc for the case) in residency. Then in private practice I went to sufenta (10-20mcg for induction and 50-100mcg for the whole case). I won't be doin that high crap any more. Pts these days are fast tracked and our hearts were frequently extubated 1-3 hrs post surgery if they weren't already extubated in the OR. High dose narcotics doesn't allow for this. Does that answer your question?

 

[jetproppilot]

Did that high dose thing (20-40 cc fentanyl for induction and about 60cc for the case) in residency. Then in private practice I went to sufenta (10-20mcg for induction and 50-100mcg for the whole case). I won't be doin that high crap any more. Pts these days are fast tracked and our hearts were frequently extubated 1-3 hrs post surgery if they weren't already extubated in the OR. High dose narcotics doesn't allow for this. Does that answer your question?

Ditto.
I loved sufenta/nitrous/oxygen/vec/a little midaz during residency for long back cases, etc...even did morpine 1mg/kg, curare .5mg/kg, midaz 5-8 mg for induction when controlled hypotension was desired...exploited the histamine release of morphine and curare....but like Noyac said its not too practical when you're trying to get everyone home quicker.
The trend now is less narcotic, not more.

 

[militarymd]

high dose narc = high likelihood of vomiting for some patients

 

[soon2bdoc2003]

for big bowel cases or whipples I'll induce with 500mcg of fentanyl and depending on the patients cv status an induction dose of ketamine or thiopental. I'll intubate with sux, paralyze with pancuronium and use nitrous and morphine for maintenance. Real challenge getting them breathing at the end with all that narcotic and panc on board but most of these patients are going to the unit anyway, otherwise I have them extubated in the pacu a couple of hours postop. Fun part is doing the entire case for less than the price of a single bottle of propofol! If you want to practice a real rapid emergence do your standard induction and use nitrous and a propol drip for maintenance.. works great for <30 minute mask cases and the patients just snap awake at the end. Probably a hundred ways to do any case.. try them all while you're still a resident.

 

[UTSouthwestern]

for big bowel cases or whipples I'll induce with 500mcg of fentanyl and depending on the patients cv status an induction dose of ketamine or thiopental. I'll intubate with sux, paralyze with pancuronium and use nitrous and morphine for maintenance. Real challenge getting them breathing at the end with all that narcotic and panc on board but most of these patients are going to the unit anyway, otherwise I have them extubated in the pacu a couple of hours postop. Fun part is doing the entire case for less than the price of a single bottle of propofol! If you want to practice a real rapid emergence do your standard induction and use nitrous and a propol drip for maintenance.. works great for <30 minute mask cases and the patients just snap awake at the end. Probably a hundred ways to do any case.. try them all while you're still a resident.

I'd put an epidural in a whipple or big exp lap case like that and start using it before induction. I've used less than 100 mcg of fentanyl or no narcotic whatsoever with a good epidural for whipples.

 

[beezar]

I'd put an epidural in a whipple or big exp lap case like that and start using it before induction. I've used less than 100 mcg of fentanyl or no narcotic whatsoever with a good epidural for whipples.

Love those epidurals for decreasing narcotic. But a lot of my attendings won't let me dose the epidural for the case (especially thoracic cases) until the end of the case, saying that you don't want to fight hypotension intraop. Doesn't make much sense to me... why not just start a pressor drip? but anyway...

To the high-dose narcotic technique... did a lap chole once giving 1000mcg fentanyl on induction to a 60 yo opioid-naive pt, average weight... just b/c my attending wanted me to see just how much fentanyl someone can take. Then ran sevo/N2O, made sure all of the gas was off at the end. Pt woke up breathing 10x/min as the dressing was being placed, following commands, extubated to the PACU. Mind you this was an academic institution where the lap chole took 1.5 hrs.

Of course, the pt was puking her guts out despite the multiple antiemetic prophylactics...

 

[UTSouthwestern]

Love those epidurals for decreasing narcotic. But a lot of my attendings won't let me dose the epidural for the case (especially thoracic cases) until the end of the case, saying that you don't want to fight hypotension intraop. Doesn't make much sense to me... why not just start a pressor drip? but anyway...

To the high-dose narcotic technique... did a lap chole once giving 1000mcg fentanyl on induction to a 60 yo opioid-naive pt, average weight... just b/c my attending wanted me to see just how much fentanyl someone can take. Then ran sevo/N2O, made sure all of the gas was off at the end. Pt woke up breathing 10x/min as the dressing was being placed, following commands, extubated to the PACU. Mind you this was an academic institution where the lap chole took 1.5 hrs.

Of course, the pt was puking her guts out despite the multiple antiemetic prophylactics...

Ask them if you can put 2 mg of Duramorph in 10-15 cc's volume into the epidural.

 

[jem04]

Ask them if you can put 2 mg of Duramorph in 10-15 cc's volume into the epidural.

Or 0.5 mg hydromorphone...

 

[jetproppilot]

Love those epidurals for decreasing narcotic. But a lot of my attendings won't let me dose the epidural for the case (especially thoracic cases) until the end of the case, saying that you don't want to fight hypotension intraop. Doesn't make much sense to me... why not just start a pressor drip? but anyway...

To the high-dose narcotic technique... did a lap chole once giving 1000mcg fentanyl on induction to a 60 yo opioid-naive pt, average weight... just b/c my attending wanted me to see just how much fentanyl someone can take. Then ran sevo/N2O, made sure all of the gas was off at the end. Pt woke up breathing 10x/min as the dressing was being placed, following commands, extubated to the PACU. Mind you this was an academic institution where the lap chole took 1.5 hrs.

Of course, the pt was puking her guts out despite the multiple antiemetic prophylactics...

Not dosing the epidural intraop is wasting alot of the reason you put the epidural in in the first place.