Intraop analgesia

[Mike1228]

I have seen and heard so many ways to treat analgesia during surgery. I understand that it often depends on the type of surgery and the patient, but I often hear the same few strategies and I was curious what everyone else does? Lets say for your typical Laparoscopic assisted Total hysterectomy

1) Induction (fentanyl, lido, prop, and Roc/Sux) --> Fentanyl bolus before incision (unless surgeon is fast and cuts right after induction) and then just intermittent fentanyl boluses (25-50 mcg) during surgery PRN with a Volatile MAC of ~0.8-1. Then titrate more fentanyl in during emergence based on respiratory rate.

2) Induction with fentanyl again --> Some opioid alternative before incision ( ex: ketamine 20 mg) with ketamine 10 mg every ~ 45 mins. Then fentanyl during emergence. So opioid only at start and at emergence.

3) Induction with fentanyl again --> Start the case with something that is long acting (Dilaudid 0.5-1 mg OR 10-20 mcg precedex bolus with another 10-20 mcg precedex nearing the end of the case) + treat any breakthroughs with fentanyl bolus/Esmolol bolus/ or just increasing gas.

****One more question: Would you use less opioid overall by giving dilaudid instead of fentanyl since one dose of dilaudid (A dose Equivalent to 50-100 mcg fentanyl) can cover you longer than redosing the fentanyl frequently during the case? This lead to less opioids and the nasty side-effects we deal with post-op.

Thanks for everyone's time

---

Members don't see this ad.

 

[BLADEMDA]

Let's see my N is over 150 of these cases. They are typically ASA 2 and straightforward. I do bilateral TAP blocks and administer about 50-100 ug Fentanyl IV. Preop they get Tylenol PO (or IV intraop if that is your preference), NSAID like celebrex or toradol (check with your gynecologist) then go home that same day. Pain scores are typically quite low for a LASH.

I have done these cases under TIVA with no opioids and again the motivated patient does quite well. I sometimes use Precedex for my cases and I would consider 1 ug/kg IV for this case if I wanted a non-opioid technique. Hypotension is likely with precedex if the bolus dose is more than 0.5 ug/kg IV so another strategy is just to use a second infusion pump or add it to the propofol (TIVA).

Large amounts of opioids for a LASH seems unnecessary most of the time IMHO.

I typically add the decadron to my local anesthetic for TAP blocks so I rarely give any additional decadron IV. If you skip the decadron with the local then decadron IV seems prudent.

https://rapm.bmj.com/content/rapm/early/2019/02/02/rapm-2018-100024.full.pdf

Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review

The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for ...

www.ncbi.nlm.nih.gov

 

[MirrorTodd]

Let's see my N is over 150 of these cases. They are typically ASA 2 and straightforward. I do bilateral TAP blocks and administer about 50-100 ug Fentanyl IV. Preop they get Tylenol PO (or IV intraop if that is your preference), NSAID like celebrex or toradol (check with your gynecologist) then go home that same day. Pain scores are typically quite low for a LASH.

I have done these cases under TIVA with no opioids and again the motivated patient does quite well. I sometimes use Precedex for my cases and I would consider 1 ug/kg IV for this case if I wanted a non-opioid technique. Hypotension is likely with precedex if the bolus dose is more than 0.5 ug/kg IV so another strategy is just to use a second infusion pump or add it to the propofol (TIVA).

Large amounts of opioids for a LASH seems unnecessary most of the time IMHO.

Basically this except we do QL's now.

 

[dhb]

I have seen and heard so many ways to treat analgesia during surgery.

You don't need analgesia under GA since there is no pain (cf. definition of pain).

 

[Ronin786]

I used to be heavy handed with narcs during residency. Now for these simple cases, esmolol on induction, dilaudid in PACU. That's it.

Gas and roc during the case, esmolol/propofol for hemodynamic swings. Ketorolac before waking up. They're not painful cases.

 

[dhb]

I used to be heavy handed with narcs during residency.

CRNArcos

 

[Ronin786]

CRNArcos

It's just so easy to control moderate pain retroactively with current fast acting agents. I see zero point in pre-empting it since everybody is going to experience some sort of pain anyways! Sans a block, which these visceral blocks do a questionable job of eliminating pain anyways.

If they're going to get narcotics, why should you bother loading a whole bunch in the OR.

 

[dhb]

The less you give the less they need, something to do with receptor occupation and signaling i suppose

 

[Reveler]

Considering the generic GA case, multimodal as best you can. If not amenable to regional, optimize non-narcotics: gabapentinoids, dexamethasone, NSAIDs, tylenol (IV if your shop readily allows), ketamine. Our residents use a lot of ketamine as part of a balanced technique. For intraop narcotics, fentanyl for swings if needed (or very short acting stuff like alfentanil or remi for specific cases) + dilaudid at the end.

Gotta say I'm interested in this idea of not treating intraop pain. Maybe we're just getting caught up in the hypothetical case presented. What would be the regimen if we're talking about a bigger open belly case like HIPEC w/ extensive debulking?

 

[Katheudontas parateroumen]

I’ve gone back and forth with opiates. I used to be heavier with opiates but then kinda thought same, patients aren’t in “pain” under anesthesia so why give it? I can see the utility of balanced anesthesia with some sevo, precedex/propofol drip along with some ketamine boluses, esmolol for hemodynamics. But then also, it just getting so complicated. Tried and true is just fentanyl induction bolus, a good bolus of something long acting like dilaudid or morphine for maintenance, ketorlac at the end for cases like this that’s aren’t too long or invasive. Opiates really do smooth things out with one agent. I haven’t followed the literature enough to say that it’s any worse outcomes (pain, pacu stay, other) that’s it’s worth the headache of blocks, drips, etc. case in point is on peds, we are going for opiate sparing as possible. A set up for a spine is seriously seems more complicated than a cardiac case. We do drips lidocaine, propofol, precedex, ketamine, but at the end give some methadone anyways. The kids do seem to do pretty well post op but not sure how much better than something more simple.

 

[Endee]

I’ve stopped giving any fentanyl on induction for most GETA cases. I still use it sometimes for shorter LMA type cases where the patient is spontaneously breathing and there’s an incision that may be stimulating and cause movement.

Replaced induction fentanyl with 30-50mg esmolol and like 24mcg or so of precedex (comes in a 20cc 4mcg/mL vial for us) given in 2cc/8mcg pushes. Typically very stable induction. Depending on the case I’ll give 4-8mg morphine or 0.5-1mg dilaudid for the whole case and 99% of the time they wake up completely comfortable and need minimal PACU narcotics.

 

[GassYous]

Considering the generic GA case, multimodal as best you can. If not amenable to regional, optimize non-narcotics: gabapentinoids, dexamethasone, NSAIDs, tylenol (IV if your shop readily allows), ketamine. Our residents use a lot of ketamine as part of a balanced technique. For intraop narcotics, fentanyl for swings if needed (or very short acting stuff like alfentanil or remi for specific cases) + dilaudid at the end.

Gotta say I'm interested in this idea of not treating intraop pain. Maybe we're just getting caught up in the hypothetical case presented. What would be the regimen if we're talking about a bigger open belly case like HIPEC w/ extensive debulking?

Thoracic epidural with 0.25 bupi. I bolus around 3-5 cc at a time.

I’ve gone back and forth with opiates. I used to be heavier with opiates but then kinda thought same, patients aren’t in “pain” under anesthesia so why give it? I can see the utility of balanced anesthesia with some sevo, precedex/propofol drip along with some ketamine boluses, esmolol for hemodynamics. But then also, it just getting so complicated. Tried and true is just fentanyl induction bolus, a good bolus of something long acting like dilaudid or morphine for maintenance, ketorlac at the end for cases like this that’s aren’t too long or invasive. Opiates really do smooth things out with one agent. I haven’t followed the literature enough to say that it’s any worse outcomes (pain, pacu stay, other) that’s it’s worth the headache of blocks, drips, etc. case in point is on peds, we are going for opiate sparing as possible. A set up for a spine is seriously seems more complicated than a cardiac case. We do drips lidocaine, propofol, precedex, ketamine, but at the end give some methadone anyways. The kids do seem to do pretty well post op but not sure how much better than something more simple.

I was trained to set up like 4 different drips in residency but it's too much hassle. Ours get esp catheters and I run ketafol plus 0.5 mac iso. Max ketamine at 200. Fent boluses, try to keep it under 500 +/- a little dilaudid. Don't need precedex and ketamine at the same time imo and I think lidocaine iv is not that great. I also put 2 of mag in the bag and run it slow.

 

[deleted875186]

For a younger patient where I don’t want to have to give more than a stick of prop, I’ll give 100 mcg fentanyl for induction. Otherwise as stated above I just give prop, roc, esmolol Up tk 0.5 mg/kg for intubation. I will give somewhere in the ballpark of 10 mcg/kg hydromorphone at the start and call it a day, along with ketorolac, decadron, gas maitinence. For the younger patient harder to keep down I’ll give up to 0.5 mg/kg ketamine at the start of the case. Tylenol PO preop if I have time, prefer not to give gaba preop unless I’m concerned about PONV and really want to avoid opioids and usually try and avoid it in older patients.

 

[2010houston]

I’ll preface this with the fact that I do almost exclusively peds now. But don’t you find that people do better with long acting vs short acting opioids? I find myself using very little fent and just give the morphine or dilaudid I plan to use up front now, and call it a day. Titrate more in at the end if I need to, but I rarely do. This vs fent-at-induction-and-then switch-to-something-else-later seems to lead to less need for additional stuff in pacu, anecdotally.

 

[Hoya11]

I have seen and heard so many ways to treat analgesia during surgery. I understand that it often depends on the type of surgery and the patient, but I often hear the same few strategies and I was curious what everyone else does? Lets say for your typical Laparoscopic assisted Total hysterectomy

1) Induction (fentanyl, lido, prop, and Roc/Sux) --> Fentanyl bolus before incision (unless surgeon is fast and cuts right after induction) and then just intermittent fentanyl boluses (25-50 mcg) during surgery PRN with a Volatile MAC of ~0.8-1. Then titrate more fentanyl in during emergence based on respiratory rate.

2) Induction with fentanyl again --> Some opioid alternative before incision ( ex: ketamine 20 mg) with ketamine 10 mg every ~ 45 mins. Then fentanyl during emergence. So opioid only at start and at emergence.

3) Induction with fentanyl again --> Start the case with something that is long acting (Dilaudid 0.5-1 mg OR 10-20 mcg precedex bolus with another 10-20 mcg precedex nearing the end of the case) + treat any breakthroughs with fentanyl bolus/Esmolol bolus/ or just increasing gas.

****One more question: Would you use less opioid overall by giving dilaudid instead of fentanyl since one dose of dilaudid (A dose Equivalent to 50-100 mcg fentanyl) can cover you longer than redosing the fentanyl frequently during the case? This lead to less opioids and the nasty side-effects we deal with post-op.

Thanks for everyone's time

For example a knee scope: 100mcg of fentanyl is all it takes. Because when they wake up there is no significant pain source (once marcaine is in the joint). Maybe give 200 rarely if its prolonged and you need to control spontaneous breathing/smooth wake up. But fentanyl will do when I know there will be nothing upon wake up and I want them up and out of PACU.

For a lap hyst: 100mcg of fentanyl on induction and then dilaudid intra-op (id say about 1mg/hr when apneic) and when breathing titrated to resp rate of 12. For the lap hyst, unlike the knee scope, there will be significant pain on awakening and throughout recovery. You might as well wake them up in a comfortable buzzed state for the first couple hours of recovery. Im not looking for them to be up and about right away as a priority.

If you have a short case with minimal pain at the end - use the short acting fentanyl to get through the case with minimal residual in PACU

If you have a long case with significant pain at the end - use the long acting dilaudid to achieve a great level of comfort over quick DC

And its important to always have some level of opiate on board while surgery is occuring. So for a longer case intra-op dilaudid makes more sense to me.

 

[Volatile]

Thoracic epidural with 0.25 bupi. I bolus around 3-5 cc at a time.


I was trained to set up like 4 different drips in residency but it's too much hassle. Ours get esp catheters and I run ketafol plus 0.5 mac iso. Max ketamine at 200. Fent boluses, try to keep it under 500 +/- a little dilaudid. Don't need precedex and ketamine at the same time imo and I think lidocaine iv is not that great. I also put 2 of mag in the bag and run it slow.

Do you guys really do thoracic epidurals or esp catheters for these cases??

a hysterectomy is basically an outpatient procedure at our shop. They get taps, a little fent/ Tylenol. Seem to do fine in pacu and are heading out the door in a couple hours.

 

[Hoya11]

I’ve stopped giving any fentanyl on induction for most GETA cases. I still use it sometimes for shorter LMA type cases where the patient is spontaneously breathing and there’s an incision that may be stimulating and cause movement.

Replaced induction fentanyl with 30-50mg esmolol and like 24mcg or so of precedex (comes in a 20cc 4mcg/mL vial for us) given in 2cc/8mcg pushes. Typically very stable induction. Depending on the case I’ll give 4-8mg morphine or 0.5-1mg dilaudid for the whole case and 99% of the time they wake up completely comfortable and need minimal PACU narcotics.

Personally I think its smoother/easier to just give the small dose of fentanyl on induction.

 

[Mike1228]

Sometimes I feel like I'm not providing a good anesthetic if I find out that the PACU had to load the patient up with narcs after. Other times I think to myself that my job is just to get the patient safely and comfortably thru surgery and that it. There's a reason there's a PACU and I shouldn't be concerned with that by risking giving the patient long acting analgesic meds when you never really can tell how a patient will respond under anesthesia, especially to only a short-term sympathetic reflex response to nociception. Unless the surgery is several hours long, is there really any reason for long acting agents like dilaudid, morphine, or precedex?? Maybe just use fentanyl, ketamine, esmolol, Volatiles, and N2O to get thru and hand off and let PACU take over lol.

 

[deleted171991]

Personally I think its smoother/easier to just give the small dose of fentanyl on induction.

I have a feeling that all the complicated anesthetic plans would have a very short lifetime in PP. Let's not mention all the fancy drugs they tend not to invest in (e.g. precedex). Residents, beware!

 

[Lidolover]

For almost every intra-abdominal surgery, unless there is a bold contraindication, I use lidocaine 100 mg on induction followed by gtt till the end of the case. Prefer dilaudid over fentanyl and definitely over morphine.

 

[MirrorTodd]

For almost every intra-abdominal surgery, unless there is a bold contraindication, I use lidocaine 100 mg on induction followed by gtt till the end of the case. Prefer dilaudid over fentanyl and definitely over morphine.

I'd expect nothing less. lol

 

[deleted171991]

Sometimes I feel like I'm not providing a good anesthetic if I find out that the PACU had to load the patient up with narcs after. Other times I think to myself that my job is just to get the patient safely and comfortably thru surgery and that it. There's a reason there's a PACU and I shouldn't be concerned with that by risking giving the patient long acting analgesic meds when you never really can tell how a patient will respond under anesthesia, especially to only a short-term sympathetic reflex response to nociception. Unless the surgery is several hours long, is there really any reason for long acting agents like dilaudid, morphine, or precedex?? Maybe just use fentanyl, ketamine, esmolol, Volatiles, and N2O to get thru and hand off and let PACU take over lol.

In my opinion, the PACU should be for observation, not treatment. Treatment delays discharge. My patient should wake up perfectly comfortable, and stay like that for at least 1-2 hours.

 

[GassYous]

Do you guys really do thoracic epidurals or esp catheters for these cases??

a hysterectomy is basically an outpatient procedure at our shop. They get taps, a little fent/ Tylenol. Seem to do fine in pacu and are heading out the door in a couple hours.

Not for a hysterectomy. I meant for the hipec that he mentioned. I've seen the patients postop and it's a pretty painful procedure.

In my opinion, the PACU should be for observation, not treatment. Treatment delays discharge. My patient should wake up perfectly comfortable, and stay like that for at least 1-2 hours.

I'm of the opinion that every patient is different and I want to give the minimum medications possible. So if they need a little more in pacu then that's fine and I prefer that over giving too much in the OR and having the effects linger.

 

[Hoya11]

I'm of the opinion that every patient is different and I want to give the minimum medications possible. So if they need a little more in pacu then that's fine and I prefer that over giving too much in the OR and having the effects linger.

Scary to think about being that patient given the "minimal" amount. Why are we trying so hard to avoid opiates? Please dont give me esmolol instead...

What is going to "linger" the analgesia? The peaceful feeling of an opiate?

Iif I have to give narcan to 1 patient in 100 (its typically a lot less) its worth it for the other 99 who wake up comfortable, instead of being so scared of that one time I had overshot. And with more experience you learn never to over shoot

 

[T-burglar]

Just give your patients the opioids and the benzos FFS. Its not a "CRNA move", they're good drugs. Make them comfortable, have you ever had intravenous lidocaine while mostly awake? I have, it sucks

 

[Tramadeezy]

Check out some of Tony Yaksh's research on pain processing after tissue injury; really fascinating stuff. He did a bunch of animal studies showing that you could prevent wind up, central sensitization etc in rats if you give morphine or a NMDA antagonist prior to a painful stimulus. Not sure how clinically relevant it is but It made me rethink being stingy with opioids during surgery. Maybe we are helping preventing chronic post surgical pain with introp opioids?

 

[deleted875186]

Check out some of Tony Yaksh's research on pain processing after tissue injury; really fascinating stuff. He did a bunch of animal studies showing that you could prevent wind up, central sensitization etc in rats if you give morphine or a NMDA antagonist prior to a painful stimulus. Not sure how clinically relevant it is but It made me rethink being stingy with opioids during surgery. Maybe we are helping preventing chronic post surgical pain with introp opioids?

This has never been demonstrated in humans.

there are multiple studies suggesting higher dose synthetic opioids intraoperative leads to high postoperative opioid requirements.

 

[deleted875186]

Sometimes I feel like I'm not providing a good anesthetic if I find out that the PACU had to load the patient up with narcs after. Other times I think to myself that my job is just to get the patient safely and comfortably thru surgery and that it. There's a reason there's a PACU and I shouldn't be concerned with that by risking giving the patient long acting analgesic meds when you never really can tell how a patient will respond under anesthesia, especially to only a short-term sympathetic reflex response to nociception. Unless the surgery is several hours long, is there really any reason for long acting agents like dilaudid, morphine, or precedex?? Maybe just use fentanyl, ketamine, esmolol, Volatiles, and N2O to get thru and hand off and let PACU take over lol.

Anesthesiologists are responsible for orders in the PACU are they not?

I personally think it’s foolish if we are not responsible for immediate postop pain. It’s literally one of the only things we are responsible for.

 

[jwk]

I've almost stopped using fentanyl after being raised on fentanyl the first 1/2 of my career. We're not big on TAP blocks yet, but we do a boatload of DaVinci gyno, urology, etc. Heavy on the multi-modal "everything but the kitchen sink", minimal narcotics whenever possible, and when I do use them, it's pretty much exclusively Dilaudid. I still get weird looks from older PACU nurses (what do you mean you didn't give any narcotics?). It still amazes me that a lot of folks think it's impossible to do any anesthetic without 100mcg of fentanyl.

I think a lot of the use of narcotics is pre-emptive for the "5th vital sign" pain score mandated by TJC years ago. I can't tell you how many PACU nurses are trying to rouse the patients who are dozing quite comfortably demanding that they tell them their pain score before the monitors are even hooked up.

 

[jwk]

For almost every intra-abdominal surgery, unless there is a bold contraindication, I use lidocaine 100 mg on induction followed by gtt till the end of the case. Prefer dilaudid over fentanyl and definitely over morphine.

I'm not sure how good the data is on lido infusions, but I give it for virtually every induction and a fair amount of time will give it a few minutes before emergence. Emory-raised by Steinhaus, what can I tell you. Lidocaine also treats cough due to cold, the heartbreak of psoriasis, and painful hemorrhoidal itching among other things.

 

[joshbc]

I have a feeling that all the complicated anesthetic plans would have a very short lifetime in PP. Let's not mention all the fancy drugs they tend not to invest in (e.g. precedex). Residents, beware!

As an attending in my 2nd year, I can attest to this 100%! This is why it is so important to practice various techniques with different drugs. Most of my group think that I have stock in precedex because I feel that it is such a game-changer and use it for most of my patients. As a side note, precedex now has a generic which is very affordable. The cost of a 200 mcg/ 2 mL vial is ~$4.

I trained at an institution where it was standard of care to use sugammadex. As it stands now, we get our hands slapped if we use it too often. I don't think I've seen anyone mention this because it's extremely important in how you manage analgesia.

Finally- I saw someone mention QL blocks... I almost laughed when I saw the cover of Anesthesiology this month with QLs being used for C sections. We do TAPs for most laparascopic procedures and can pretty much have them done by the time the CRNA has intubated the patient. I get that the QL blocks offer some benefits over the TAPs (visceral coverage, lower abdominal coverage) in theory, but I just don't see a role for these in the real world. Do people actually do these in private practice?

 

[vector2]

This has never been demonstrated in humans.

there are multiple studies suggesting higher dose synthetic opioids intraoperative leads to high postoperative opioid requirements.

If you’re talking about remifentanil infusions in spines, yes.

But this doesn’t apply to all opioids or all surgeries. In fact, giving a big onetime slug of methadone upfront can reduce intraoperative, PACU, in-hospital, and 30 day opioid usage.

 

[GassYous]

As an attending in my 2nd year, I can attest to this 100%! This is why it is so important to practice various techniques with different drugs. Most of my group think that I have stock in precedex because I feel that it is such a game-changer and use it for most of my patients. As a side note, precedex now has a generic which is very affordable. The cost of a 200 mcg/ 2 mL vial is ~$4.

I trained at an institution where it was standard of care to use sugammadex. As it stands now, we get our hands slapped if we use it too often. I don't think I've seen anyone mention this because it's extremely important in how you manage analgesia.

Finally- I saw someone mention QL blocks... I almost laughed when I saw the cover of Anesthesiology this month with QLs being used for C sections. We do TAPs for most laparascopic procedures and can pretty much have them done by the time the CRNA has intubated the patient. I get that the QL blocks offer some benefits over the TAPs (visceral coverage, lower abdominal coverage) in theory, but I just don't see a role for these in the real world. Do people actually do these in private practice?

It's not that much different from doing the tap, especially the ql1 and I think it helps more. Tap blocks are a lot more variable.

 

[DrOwnage]

Love hearing everyone's different approaches. Just goes to show that anesthesia is such a flexible and dynamic process, no one way is correct. Practicing in absolutes and doing the same thing for every single case however... We all must learn to love every medication in our arsenal and realize there is room for them when necessary. I will echo the sentiment that private practice will change the way you practice. Most of it has to do with timing and speed of surgeons. However for most of my cases not at extremes of age and > 2 hours, my go to induction is 1.5mg/kg of propofol, 0.5mg/kg ketamine, 1mg/kg of lidocaine, and 20-30 of esmolol prior to intubation (or less depending on resting heart rate/beta blocked patient). Then dilaudid titrated in 30-45 minutes prior to extubation. The peak effect of dilaudid is 30-45 minutes, much longer than people expect. I've found dosing it up during that time period makes a big difference rather than 10 minutes before the tube comes out.

 

[deleted171991]

Love hearing everyone's different approaches. Just goes to show that anesthesia is such a flexible and dynamic process, no one way is correct. Practicing in absolutes and doing the same thing for every single case however... We all must learn to love every medication in our arsenal and realize there is room for them when necessary. I will echo the sentiment that private practice will change the way you practice. Most of it has to do with timing and speed of surgeons. However for most of my cases not at extremes of age and > 2 hours, my go to induction is 1.5mg/kg of propofol, 0.5mg/kg ketamine, 1mg/kg of lidocaine, and 20-30 of esmolol prior to intubation (or less depending on resting heart rate/beta blocked patient). Then dilaudid titrated in 30-45 minutes prior to extubation. The onset of dilaudid is 30-45 minutes, much longer than people expect. I've found dosing it up during that time period makes a big difference rather than 10 minutes before the tube comes out.

No, it's not 30-45 minutes.

"2. Parenteral

Peak plasma levels occur soon after administration when hydromorphone given by i.v. injection, but levels then decline rapidly owing to rapid distribution into liver, spleen, kidney, and skeletal muscles [51, 55, 80, 107]. They decline by as much as 63% after 3 min of administration (90% after 10 min) [51, 55, 56, 80, 107]. The onset of analgesia occurs within 5 min after i.v. administration [20]. The maximum analgesic effect occurs 8–20 min (lag time) after the maximum plasma concentration [20, 80]. This lag time is most probably due to a delay in penetration of the blood–brain barrier owing to low lipid solubility [20]. Mean bioavailability after a subcutaneous (s.c.) infusion is 78% that of an i.v. infusion [79]. The mean initial maintenance s.c. infusion dose following dose titration is almost three times the preinfusion dose [77, 78]. Unfortunately, no pharmacokinetic data are available for uptake from s.c. tissue. Hydromorphone is about 10 times as lipid soluble as morphine [117], so that s.c. absorption into the systemic 87 circulation might be faster, increasing the bioavailability of hydromorphone compared with morphine [78]. Intramuscular administration can be used but is not advised for emaciated, cachectic, or elderly patients, making the s.c. route a suitable alternative [53]. Absorption may be slower after i.m. than after s.c. administration [46], so that relief of cancer pain may not occur until after the third or fourth dose [6]."

Hydromorphone: pharmacology and clinical applications in cancer patients | SpringerLink (apologies for the paywall)

 

[DrOwnage]

Sorry meant to say "peak effect."

 

[Southpaw]

I see a lot of well intentioned anesthetics involving lidocaine/precedex/ketamine/benadryl/whatever, all to avoid opioids intraop, that more often than not do nothing other than keep the patient in PACU longer, keep the patient asleep longer, and simply delay the time to admin for dilaudid/morphine as when they do inevitably wake up they'll be in pain.

Unless your anesthetic involves neuraxial/regional, keep it simple and give fentanyl. Get the patient spontaneously breathing ASAP and titrate fentanyl to RR for emergence. Keep the resp rate < 16. Your day, my day, and the patients anesthetic all will go smoother.

Treat PONV preemptively and aggressively. I don't like morphine or dilaudid intraop because no matter what happens in the OR or what anesthetic has been chosen, the PACU RN is going to give some long acting opioid post op most of the time. And if dilaudid/morphine has been given intraop and then given post op, then be ready to keep the patient around for a while due to PONV.

 

[T-burglar]

I see a lot of well intentioned anesthetics involving lidocaine/precedex/ketamine/benadryl/whatever, all to avoid opioids intraop, that more often than not do nothing other than keep the patient in PACU longer, keep the patient asleep longer, and simply delay the time to admin for dilaudid/morphine as when they do inevitably wake up they'll be in pain.

Unless your anesthetic involves neuraxial/regional, keep it simple and give fentanyl. Get the patient spontaneously breathing ASAP and titrate fentanyl to RR for emergence. Keep the resp rate < 16. Your day, my day, and the patients anesthetic all will go smoother.

Treat PONV preemptively and aggressively. I don't like morphine or dilaudid intraop because no matter what happens in the OR or what anesthetic has been chosen, the PACU RN is going to give some long acting opioid post op most of the time. And if dilaudid/morphine has been given intraop and then given post op, then be ready to keep the patient around for a while due to PONV.

Thank you . Just give some fentanyl and stop trying to reinvent the wheel. You’re not clever because you can put someone in a medically induced coma all to avoid some opioids .

 

[zizzer]

I read most of the replies, but not all, but felt like sharing my approach as well.

Pain (the perception of nociception) doesn't exist under general anesthesia; however, nociception can sensitize pain pathways, resulting in hyperalgesia afterwards. Think about the "dolor" aspect of inflammation we learn about in medical school. When you cut yourself, the red area is very painful when you barely touch it, right? That's hyperalgesia, and the same thing happens under general anesthesia with a scalpal incision both peripherally and at the level of the dorsal root ganglion.

So if we can prevent this pain transmission and upregulation of all these various types of receptors, why not? To this end, it's just about selecting a balanced multimodal analgesic plan that can minimize side effects. Unless unable to for some reason, I will aim to use acetaminophen, ketorolac or celecoxib, low-dose ketamine (this one's pretty key I think), nerve blocks, dexamethasone, and opioids for any case with a substantial pain component to it. Some use gabapentin, dexmedetomidine, and lidocaine infusions, but I tend to start thinking they're more trouble than their worth at this point and don't seem to need them. Of note, don't waste your time with a ketamine infusion. Give 0.25-0.5mg/kg pre-incision and you may not have to even redose. I recommend using a pharmacokinetic app until you get the hang of it.

Of particular note is that I don't think it's necessary to avoid opioids to the extent that people do intraoperatively and immediately postoperatively.
Addiction has really only been linked to the people going home with too many as an outpatient, and I'm not convinced that acute opioid-induced hyperalgesia exists (difficult to differentiate from acute tolerance, which is usually manageable). I don't think I go overboard, but a medium amount of opioid use helps a lot I think without the downside I think some people attribute to them.

TL;DR; use a multimodal approach and don't treat opioids like the boogeyman

 

[deleted875186]

If you’re talking about remifentanil infusions in spines, yes.

But this doesn’t apply to all opioids or all surgeries. In fact, giving a big onetime slug of methadone upfront can reduce intraoperative, PACU, in-hospital, and 30 day opioid usage.

Methadone is a whole different opioid, distinct from others, different opioid receptor affinities.

Also this is exactly my point, patients do better with longer acting opioids, rather than short acting potent opioids for only intraop analgesia. The data is certainly overwhelming I would say that remifentanyl causes higher post op opioid requirements, some data to suggest fentanyl is similar but I think it’s reasonable to infer that the same phenomenon exists with fentanyl and sufenta.

also, I think calling methadone opioid sparing is a misnomer, your just giving a giant dose of an opioid that gives 2-3 days of pain relief. The original papers where with 20 mg IV methadone at induction, which is 40 mg PO, or somewhere around 160 MME, a big dose. Part of the reason it works better is avoiding peaks and troughs associated with shorter acting opioids.

 

[deleted875186]

I see a lot of well intentioned anesthetics involving lidocaine/precedex/ketamine/benadryl/whatever, all to avoid opioids intraop, that more often than not do nothing other than keep the patient in PACU longer, keep the patient asleep longer, and simply delay the time to admin for dilaudid/morphine as when they do inevitably wake up they'll be in pain.

Unless your anesthetic involves neuraxial/regional, keep it simple and give fentanyl. Get the patient spontaneously breathing ASAP and titrate fentanyl to RR for emergence. Keep the resp rate < 16. Your day, my day, and the patients anesthetic all will go smoother.

Treat PONV preemptively and aggressively. I don't like morphine or dilaudid intraop because no matter what happens in the OR or what anesthetic has been chosen, the PACU RN is going to give some long acting opioid post op most of the time. And if dilaudid/morphine has been given intraop and then given post op, then be ready to keep the patient around for a while due to PONV.

I agree.

still doesn’t mean I can’t shoot to drop the patient off in PACU with some long acting opioid so they’re comfortable. I agree post PACU nurses do tend to give too much opioid.

the idea that using more fentanyl and less long acting to avoid PONV in the PACI is simply kicking the can down the road, patient will get post discharge nausea and vomiting at home or on the floor when they take more opioid for their pain. Why not try to get them comfortable with long acting in the first place?

 

[vector2]

Methadone is a whole different opioid, distinct from others, different opioid receptor affinities.

Also this is exactly my point, patients do better with longer acting opioids, rather than short acting potent opioids for only intraop analgesia. The data is certainly overwhelming I would say that remifentanyl causes higher post op opioid requirements, some data to suggest fentanyl is similar but I think it’s reasonable to infer that the same phenomenon exists with fentanyl and sufenta.

also, I think calling methadone opioid sparing is a misnomer, your just giving a giant dose of an opioid that gives 2-3 days of pain relief. The original papers where with 20 mg IV methadone at induction, which is 40 mg PO, or somewhere around 160 MME, a big dose. Part of the reason it works better is avoiding peaks and troughs associated with shorter acting opioids.

Agreed.


But in regard to methadone being opioid-sparing, I think it reduces opioid consumption even after it’s been eliminated, although the evidence is still weak at this point (30d opioid usage in the study I linked is pt reported). This may be due to the receptor affinity you point out and its NMDA antagonism at the time of the initial painful stimulus.

 

[GassYous]

Patients waking during surgery?

I know this phenomenon occurs, and I just watched a new report on CBS that was on this subject. It sparked my interest, since I have interest in surgery. Perhaps this is better in the anesthesia forums, I don't know, but I wondered what kind of take those in surgery residency and out in...

forums.studentdoctor.net

Just wanted to repost this gem of a thread about intraoperative pain

 

[deleted697535]

It's a lap tah??
Draw up a 30 ml syringe with however much prop roc fent dilauid ancef dex nsaid du jour will fit, push that then sit down for 90mins

Be grand

 

[Aether2000]

If I do a block plus TIVA or GA, then no opioids during surgery. Without a block, I may add opioid at the end of the procedure before extubation but only after they are breathing with a decent rate and TV on their own off ventilator. Opioids are probably drastically overused during surgery and can lead to increased usage post op and potentially chemical dependency. It is astonishing how a patient with complete anesthesia from a brachial plexus block ends up receiving 250mcg fentanyl while on a phenylephrine drip for a sitting shoulder procedure, only to enter PACU nauseated but still completely anesthetic over the entire shoulder and neck.

 

[GassYous]

If I do a block plus TIVA or GA, then no opioids during surgery. Without a block, I may add opioid at the end of the procedure before extubation but only after they are breathing with a decent rate and TV on their own off ventilator. Opioids are probably drastically overused during surgery and can lead to increased usage post op and potentially chemical dependency. It is astonishing how a patient with complete anesthesia from a brachial plexus block ends up receiving 250mcg fentanyl while on a phenylephrine drip for a sitting shoulder procedure, only to enter PACU nauseated but still completely anesthetic over the entire shoulder and neck.

why would you block and give any fentanyl lol
i give a little versed and ketamine for the block and that's about it

 

[deleted875186]

Patients waking during surgery?

I know this phenomenon occurs, and I just watched a new report on CBS that was on this subject. It sparked my interest, since I have interest in surgery. Perhaps this is better in the anesthesia forums, I don't know, but I wondered what kind of take those in surgery residency and out in...

forums.studentdoctor.net

Just wanted to repost this gem of a thread about intraoperative pain

This thread is great.

 

[Aether2000]

why would you block and give any fentanyl lol
i give a little versed and ketamine for the block and that's about it

I do the blocks, but others then give the fentanyl....

 

[deleted875186]

why would you block and give any fentanyl lol
i give a little versed and ketamine for the block and that's about it

I’ve never given ketamine/versed for sedation prior to a block in a healthy patients. How much do you give? Ever have people with bad reactions. Why do you prefer it over versed/fentanyl.

 

[Arch Guillotti]

why would you block and give any fentanyl lol
i give a little versed and ketamine for the block and that's about it

Ketamine for a routine block? How much?