I blame you guys for this

[epidural man]

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If you friggin arse-holes would have used it more - they would have not gone out of business, and I could still be using my wonder drug.

Alfentanil (1976-2023)

www.uclahealth.org

 

[norski]

We still use it in Scandinavia. Made in Germany. Beautiful for colos,urethral stents, ER/ICU tubing, plenty other uses, of course. I hate remi with a passion as a hand bolus drug (outside of infusions,tci or not), so when I want the very quick onset and short action with very minimal drawbacks, Al's my friend.

 

[epidural man]

We still use it in Scandinavia. Made in Germany. Beautiful for colos,urethral stents, ER/ICU tubing, plenty other uses, of course. I hate remi with a passion as a hand bolus drug (outside of infusions,tci or not), so when I want the very quick onset and short action with very minimal drawbacks, Al's my friend.

VERY LUCKY!!!

It is nearly a perfect drug.

 

[deleted1130227]

Al's beloved sister Sue also passed at exactly the the same time. Just like in The Notebook.

 

[coffeebythelake]

agree it is a great drug

 

[Blockit]

Well dammit…it was a great drug for blocks 😢

 

[epidural man]

Al's beloved sister Sue also passed at exactly the the same time. Just like in The Notebook.

Wait…what?

 

[coffeebythelake]

Wait…what?

Perhaps referring to sufentanil which is also off the market at this time. There are 2 manufacturers for sufenta, though, so maybe it isn't permanent.

 

[epidural man]

Perhaps referring to sufentanil which is also off the market at this time. There are 2 manufacturers for sufenta, though, so maybe it isn't permanent.

Now this is also a tragedy. Since Alfentanil is gone, I said to my self - I guess it’s time to get reacquainted with my old pal sufenta.

I guess that won’t happen.

 

[GassYous]

Whats wrong with good ol fentanyl

 

[deleted1130227]

Whats wrong with good ol fentanyl

Doesn’t cost enough.

 

[norski]

Whats wrong with good ol fentanyl

Too slow onset, too long effect. Which is great for long haul surgeries and sick ones, not so great for short and sweet. Great as a single drug for shoulder reductions,too (I may be mistaken, but these might be handled mostly in the ED in the US?).

 

[epidural man]

Doesn’t cost enough.

Alfentanil was cheaper than fentanyl I think.

 

[epidural man]

Whats wrong with good ol fentanyl

This -

If you mix 2000mcg (alfentanil) in a 100ml bottle of propofol - and infuse that for the case, it makes the perfect anesthetic.

After the propofol wears off, the alfenta hangs a round a bit giving perfect analgesia in the recovery room.

Also, it doesn't matter the length of the case, you can keep that infusion going with no worries about the drug stacking up and biting you on the back end (which fentanyl can do).

 

[Hoya11]

Alfentanil was cheaper than fentanyl I think.

everybody already has fentanyl tho, so its adding something else.. for kind of no reason.

i have not had a problem with fentanyl "hanging around" when dosed correctly

 

[pgg]

I used to use a alfentanil along with propofol to stun people for short, painful procedures. Like painful blocks administers by surgeons followed by a MAC anesthetic. Good for stuff like retrobulbar blocks and extremity blocks. Surgeons just don't seem to be able to do those gently, stab stab stab slam the local in.

A slug of propofol and a couple hundred mcg alfentanil and they're out (and importantly also perfectly still) for a minute or two, then the drugs are gone.

If you mix 2000mcg (alfentanil) in a 100ml bottle of propofol - and infuse that for the case, it makes the perfect anesthetic.

It is nice, but I've become less of a fan of infusions of potent short acting synthetic opioids (basically the remi su and al -fentanils), since I think opioid induced hyperalgesia is a thing. About the only time I do it now is to balance the reduced volatile levels in cases requiring neuromonitoring - and the current group of monitoring people I work with don't really seem to care about volatile anesthetics so mostly I just run a MAC of gas and no opioid infusion.

So while I sort of miss alfentanil and sufentanil ... I guess I don't really.

 

[Twiggidy]

Res

Too slow onset, too long effect. Which is great for long haul surgeries and sick ones, not so great for short and sweet. Great as a single drug for shoulder reductions,too (I may be mistaken, but these might be handled mostly in the ED in the US?).

Respectfully....i'm not sure i agree with this. At least in my practice fentanyl does a great job for short and sweet cases.

 

[coffeebythelake]

I used to use a alfentanil along with propofol to stun people for short, painful procedures. Like painful blocks administers by surgeons followed by a MAC anesthetic. Good for stuff like retrobulbar blocks and extremity blocks. Surgeons just don't seem to be able to do those gently, stab stab stab slam the local in.

A slug of propofol and a couple hundred mcg alfentanil and they're out (and importantly also perfectly still) for a minute or two, then the drugs are gone.


It is nice, but I've become less of a fan of infusions of potent short acting synthetic opioids (basically the remi su and al -fentanils), since I think opioid induced hyperalgesia is a thing. About the only time I do it now is to balance the reduced volatile levels in cases requiring neuromonitoring - and the current group of monitoring people I work with don't really seem to care about volatile anesthetics so mostly I just run a MAC of gas and no opioid infusion.

So while I sort of miss alfentanil and sufentanil ... I guess I don't really.

Sufentanil isn't short acting...

 

[Dantrolene FC]

Why even give opioids during the case? Just load them up with Dilaudid at the end.

 

[caligas]

CRNA/academic nerd drug.

 

[epidural man]

CRNA/academic nerd drug.

Alfenta nerd drug?

Tell me about your experience using it. How often? What cases did you use it? When did you like it? When didn't you like it? Why didn't you like it? Ya know...stuff like that.

 

[Radar26]

If you friggin arse-holes would have used it more - they would have not gone out of business, and I could still be using my wonder drug.

Alfentanil (1976-2023)

www.uclahealth.org

Used it all the time for our ECT gig. Not sure why there was only 1 company manufacturing al, but it sounds like there were big problems with Akorn beyond keeping up a steady demand for al.

Bankrupt Akorn Pharma calls it quits and closes all US sites, laying off entire workforce


We had to switch to remi which has worked fine. It was felt by those of us who do ECT that fentanyl’s onset would be too slow and effective doses would delay wake up/discharge.

 

[jwk]

Alfenta nerd drug?

Tell me about your experience using it. How often? What cases did you use it? When did you like it? When didn't you like it? Why didn't you like it? Ya know...stuff like that.

We haven’t had alfenta on formulary in 25 years. Ditto for remi until we got a new neurosurgeon who demanded it for “quick wake-up’s”, with no clue that our wakeups are always quick.

 

[Twiggidy]

We haven’t had alfenta on formulary in 25 years. Ditto for remi until we got a new neurosurgeon who demanded it for “quick wake-up’s”, with no clue that our wakeups are always quick.

I'm not sure it's ever good to "demand" anything but I'll at least show him some support on using Remi. It was used for basically every Neuro case at my training program

 

[coffeebythelake]

CRNA/academic nerd drug.

It has niche uses and it works great. Just because you don't do those sort of cases frequently and just because you forgot there were other opioids out there doesn't mean it is some obscure drug relegated to the history books (well, now it will be)

 

[nimbus]

Alfentanil was popular in our department during my training years. It was the pet drug of two of the faculty members. Alfentil/propofol worked reasonably well for intubation, better than propofol+mivacurium😉.

Haven’t seen it since residency and I can’t say I miss it.

 

[deleted1130227]

Alfentanil was popular in our department during my training years. It was the pet drug of two of the faculty members. Alfentil/propofol worked reasonably well for intubation, better than propofol+mivacurium😉.

Haven’t seen it since residency and I can’t say I miss it.

It was a solution looking for a problem.

 

[nimbus]

We haven’t had alfenta on formulary in 25 years. Ditto for remi until we got a new neurosurgeon who demanded it for “quick wake-up’s”, with no clue that our wakeups are always quick.

You are correct that quick wakeups can be achieved without remi. The greater utility of remi is that it doesn’t interfere with neuromonitoring.

 

[PainDrain]

Didn’t alfentanil have that horrible side effect of making some patients barf immediately after giving it? We had one surgeon who loved it and demanded we use it for his MAC cases. Only problem was his patients were usually dry heaving under the drapes.

 

[GassYous]

Used it all the time for our ECT gig. Not sure why there was only 1 company manufacturing al, but it sounds like there were big problems with Akorn beyond keeping up a steady demand for al.

Bankrupt Akorn Pharma calls it quits and closes all US sites, laying off entire workforce


We had to switch to remi which has worked fine. It was felt by those of us who do ECT that fentanyl’s onset would be too slow and effective doses would delay wake up/discharge.

Why do you need it for ect?
glyco pent sux bag shock

 

[woopedazz]

Why do you need it for ect?
glyco pent sux bag shock

Alf reduces seizure threshold and also reduces propofol/hypnotic requirements = better seizures.

I don't use it routinely in ECT. But I do use it for a lot of neuro IR, or young bitey guys getting short, painful procedures under lma.

 

[coffeebythelake]

Why do you need it for ect?
glyco pent sux bag shock

They want a certain duration of seizure with ECT to be an "effective" treatment. We use it when we alter the usual recipe. Alfentanil reduces seizure threshold and it reduces the amount of induction agent you use.

Our usual usual recipe is methohexital and suxx, hyperventilate then shock.

 

[coffeebythelake]

Didn’t alfentanil have that horrible side effect of making some patients barf immediately after giving it? Only problem was his patients were usually dry heaving under the drapes.

Never seen this happen and I've used alfentanil quite a bit

 

[Airway]

Related

Mourning Physostigmine

Indulge me as I mourn the loss of physostigmine and nerd out on a really, really cool ancient botanical drug.

alyssaburgart.substack.com

 

[MirrorTodd]

Why do you need it for ect?
glyco pent sux bag shock

Man, I ain't seen pentobarbital a single day in my life.

 

[caligas]

Alfenta nerd drug?

Tell me about your experience using it. How often? What cases did you use it? When did you like it? When didn't you like it? Why didn't you like it? Ya know...stuff like that.

I’m mostly kidding. I’ve used it for retrobulbar blocks and it’s fine. The last time I saw it used (not my patient) a CRNA pushed in with sux to induce a patient that needed to be intubated and they went into asystole.

 

[coffeebythelake]

I’m mostly kidding. I’ve used it for retrobulbar blocks and it’s fine. The last time I saw it used (not my patient) a CRNA pushed in with sux to induce a patient that needed to be intubated and they went into asystole.

U think it was the alfenta or u think it was the suxx?

 

[Arch Guillotti]

U think it was the alfenta or u think it was the suxx?

Both

 

[coffeebythelake]

Both

is alfentanil more likely to induce severe bradycardia compared to say an equipotent dose of fentanyl?

 

[caligas]

is alfentanil more likely to induce severe bradycardia compared to say an equipotent dose of fentanyl?

I think the combo has been known to do it, probably could do it with any narcotic combined with sux in patient with ph 6.9 (guessing) from poor ventilation

 

[Radar26]

Why do you need it for ect?
glyco pent sux bag shock

Surprisingly, patients develop a “tolerance” to stimulation that induce seizures (just like a a drug tolerance can be built up). So the name of the game becomes reducing the dosage of anything that raises the seizure threshold and adding stimulants (flumaz, caffeine, changing to bitemporal) to help keep the stimulus above the seizure threshold despite the built up tolerance. These patients can receive ECT 3 times a week for a month- so you can imagine tolerance can build up fast. Al allowed for a good reduction in your induction agent dose which can make all the difference in obtaining an effective seizure in the frequent flyer patient.

Also we use methohexitol as our typical induction agent. And don’t forget the bite block between bag and shock 😉

 

[GassYous]

Sorry yes we used methohexitol too, I was just doing the ol prop sux tube routine

We hyperventilate to decrease the seizure threshold

 

[epidural man]

is alfentanil more likely to induce severe bradycardia compared to say an equipotent dose of fentanyl?

No

 

[pgg]

We do our ECTs with propofol and succinylcholine. I was surprised when I showed up that methohexital wasn't being used, but the psychiatrist seems to be happy with the seizures. I hyperventilate before they give the stim because I don't like desaturations but I guess it's helpful to lower the seizure threshold.

At my old job we had a protocol which was a complex cocktail of glycopyrrolate, ketorolac, methohexital, succinylcholine, and esmolol. I can't say that I see any real difference giving 5 drugs instead of 2.

 

[Gern Blansten]

Too bad. My second favorite Al of all-time behind: