Intraop analgesia

[Drwine]

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.

I have had surgery only once and my only request was to not give me any narcotic unless I was awake after the surgery and asked for them if I felt my pain was otherwise intolerable. When the nurses came around postop to offer prn narcotics post op, I sent them to get me a new ice pack. I did not take a single narcotic dose post op. I realize pain tolerance varies from patient to patient and if patients wake up in pain, I treat it but I cringe at how many blast patients with 2mg Dilaudid prior to emergence routinely.

I started cardiac anesthesia in the era when the dogma was that inhalation agents were avoided and 70-80ug fentanyl/kg or 10-20 ug/kg sufenta were given with valium and later midazolam with pancuronium was the anesthetic. My thinking on narcotics intraop has changed drastically over my career.

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[BLADEMDA]

My average dose of Fentanyl (intraop) for outpatients these days is a total of 50 micrograms. How much of that contributes to postop N/V is uncertain but my guess is very little. If they have a history of N/V with anesthesia my average dose (intraop) is zero. I also do not give morphine or dilaudid to patients in the O.R. having outpatient surgery. I reserve those for PACU if needed.

As for Ketamine I use it on occasion but less so for outpatient procedures. My dosage is low in the 25-50 mg IV range intraop when I do use it for outpatients. FYI, I have had several women complain about "feeling funny" from the low dose ketamine in the PACU. Contrary to what you read on SDN and the studies a small percentage of people, particularly women, are not fans of ketamine.

The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED - PubMed

Use of LDK as an analgesic in a diverse ED patient population appears to be safe and feasible for the treatment of many types of pain.

pubmed.ncbi.nlm.nih.gov

Eighteen patients (3.5%) experienced psychomimetic or dysphoric reactions.

 

[woopedazz]

Any of you academic guys ever induce with Dilaudid? I use Oxycodone relatively frequently for IV induction for big/painful cases where I want to keep things simple and the boss wants MOP saturation. Just mention it because OP seems pretty set in inducing all patients with fentanyl. You can induce with slower/more potent agents if you feel like it and plan it correctly.

 

[GassYous]

No bad reactions with ketamine that I've heard about yet. For the old people, I give maybe 15-20 only and nothing else. They get totally dissociated and when I asked them about it in pacu they really enjoy it. They report that it made them feel like they are watching their bodies from the outside. Have had two people tell me it was the best experience of their life. I've done blocks, spinals and thoracic epidurals with just this. Totally awake otherwise and shorter pacu stays. I avoid versed in the old patients.

For younger people I give 1-2 of versed and 20-30 of ketamine. They are totally comfortable for the block, don't move at all with needle. No local. I have had two patients have a bunch of secretions, one I needed to pop out the lma and tube (shoulder case) but I'm not sure if it's due to the ketamine or if they were just juicy. I like ketamine though because they are awake enough to tell me if there's too much pressure when injecting but otherwise totally comfortable and unlikely to have any respiratory issues. I don't even put a facemask on. I've seen other docs give too much versed/fent or even prop and now the patients apneic but still moves when they feel the block needle so it's the worst of both worlds.

Like blade I also keep the fentanyl to less than 100 for outpatients. I respect his experience and I'm sure there are people who don't like the ketamine. I keep it less than 30 total except for spines.

Not an academic but for the slightly longer and more painful cases I will give dilaudid 1 or morphine 10 upfront, no fent.

 

[deleted697535]

I gave ketamine to an awake lady one time pre thoracic epidural and she tried to lick my ear.

Which is fine.

Im sure one off, small doses of fentanyl intraop ruin most patients lives forever so its reasonable to never use it with a block. There is convincing evidence for that

 

[DrOwnage]

I know it sounds weird... But I can usually tell by talking to a patient preoperatively how they will do with decent doses of ketamine. From my experience the more chill personality people, or people with preoperative depression do well with ketamine. Also people who are cooperative and reasonable.

 

[woopedazz]

I know it sounds weird... But I can usually tell by talking to a patient preoperatively how they will do with decent doses of ketamine. From my experience the more chill personality people, or people with preoperative depression do well with ketamine. Also people who are cooperative and reasonable.

So, maybe people with low sedative requirements do well with low-dose sedative?
Do you reckon you might be slightly underdosing the rest?

 

[dhb]

My average dose of Fentanyl (intraop) for outpatients these days is a total of 50 micrograms. How much of that contributes to postop N/V is uncertain but my guess is very little. If they have a history of N/V with anesthesia my average dose (intraop) is zero. I also do not give morphine or dilaudid to patients in the O.R. having outpatient surgery. I reserve those for PACU if needed.

As for Ketamine I use it on occasion but less so for outpatient procedures. My dosage is low in the 25-50 mg IV range intraop when I do use it for outpatients. FYI, I have had several women complain about "feeling funny" from the low dose ketamine in the PACU. Contrary to what you read on SDN and the studies a small percentage of people, particularly women, are not fans of ketamine.

The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED - PubMed

Use of LDK as an analgesic in a diverse ED patient population appears to be safe and feasible for the treatment of many types of pain.

pubmed.ncbi.nlm.nih.gov

Eighteen patients (3.5%) experienced psychomimetic or dysphoric reactions.

What are you acheiving with 50mcg of fentanyl? If you're going to give such a small dose why not forgo it altogether?

 

[Katheudontas parateroumen]

I know it sounds weird... But I can usually tell by talking to a patient preoperatively how they will do with decent doses of ketamine. From my experience the more chill personality people, or people with preoperative depression do well with ketamine. Also people who are cooperative and reasonable.

For sure, it appears that way with any analgesic needs. I am a slow inducer and like to see the amount of propofol needed to put someone out. Titration got slowly, not just slugging it. Surprisingly I don’t usually need 2-3 mg/kg for the vast majority. I then titration my narcs sometimes to that. Someone I’d bolus 0.5mg dilaudid maybe only needs 0.2. Something like that. No exact science haha. But just an idea I like to say to myself that I’m giving individualized anesthesia.

 

[nimbus]

For sure, it appears that way with any analgesic needs. I am a slow inducer and like to see the amount of propofol needed to put someone out. Titration got slowly, not just slugging it. Surprisingly I don’t usually need 2-3 mg/kg for the vast majority. I then titration my narcs sometimes to that. Someone I’d bolus 0.5mg dilaudid maybe only needs 0.2. Something like that. No exact science haha. But just an idea I like to say to myself that I’m giving individualized anesthesia.

Yeah average cardioversion is out for 5-10min with 50mg of propofol.

 

[GassYous]

Yeah average cardioversion is out for 5-10min with 50mg of propofol.

On the other hand I've seen some people go to sbp 200+ after 200 of prop after intubation

 

[Arch Guillotti]

On the other hand I've seen some people go to sbp 200+ after 200 of prop after intubation

?

Cardioversion is completely separate from an induction with intubation.

 

[2Fast2Des]

What are you acheiving with 50mcg of fentanyl? If you're going to give such a small dose why not forgo it altogether?

I also usually do 50mcg max at the fast paced asc and pts do pretty well actually, not too uncomfortable. This is provided that surgeon gives well placed local also. Patients wake up quickly and are usually pretty good to go without having to stick around too long in recovery.

 

[T-burglar]

I gave ketamine to an awake lady one time pre thoracic epidural and she tried to lick my ear.

Which is fine.

Im sure one off, small doses of fentanyl intraop ruin most patients lives forever so its reasonable to never use it with a block. There is convincing evidence for that

Early in training I gave a woman having a vascular procedure a small dose of ketamine by itself and as it hit her brain she inhaled very deeply, and then let out a 20 second sustained blood curdling scream until everyone in the room got really concerned.

Never did that sh it again

 

[deleted875186]

What are you acheiving with 50mcg of fentanyl? If you're going to give such a small dose why not forgo it altogether?

I think fentanyl is quite potent. 50 mcg is usually sufficient to prevent any movement to an incision when used under GA with an LMA.

on the other hand, my personal pet peeve is the “250 mcg fentanyl” I see all the time for minor surgeries, some folks just give the whole vial, if it was 350 mcg vial I’m sure they’d give the whole thing and call that a “normal dose”

 

[MirrorTodd]

I think fentanyl is quite potent. 50 mcg is usually sufficient to prevent any movement to an incision when used under GA with an LMA.

on the other hand, my personal pet peeve is the “250 mcg fentanyl” I see all the time for minor surgeries, some folks just give the whole vial, if it was 350 mcg vial I’m sure they’d give the whole thing and call that a “normal dose”

Well when it's the end of the day and your attending has disappeared and the nurses either can't or won't waste meds with you, what else is a young enterprising resident supposed to do?

 

[GassYous]

I think fentanyl is quite potent. 50 mcg is usually sufficient to prevent any movement to an incision when used under GA with an LMA.

on the other hand, my personal pet peeve is the “250 mcg fentanyl” I see all the time for minor surgeries, some folks just give the whole vial, if it was 350 mcg vial I’m sure they’d give the whole thing and call that a “normal dose”

Several times now I've given 50 of fent and then they go apneic for 10 minutes with a second dose of 50 of fent. It is very annoying.

 

[deleted697127]

Several times now I've given 50 of fent and then they go apneic for 10 minutes with a second dose of 50 of fent. It is very annoying.

Some day I’ll learn to not give 50 of fent when the patient moves a little with an Lma that works for spontaneous ventilation but doesn’t seat well enough for assistance if they go apneic...

 

[nimbus]

Some day I’ll learn to not give 50 of fent when the patient moves a little with an Lma that works for spontaneous ventilation but doesn’t seat well enough for assistance if they go apneic...

Try upsizing all your LMAs

 

[T-burglar]

A very small dose of ketamine on top of your small dose of fentanyl is a fairly reliable way to prevent ANY movement in someone spontaneously breathing through an LMA . Even for fairly painful procedures . And generally won’t be nearly as likely to cause apnea as attempting to titrate more opioid

 

[deleted875186]

Some day I’ll learn to not give 50 of fent when the patient moves a little with an Lma that works for spontaneous ventilation but doesn’t seat well enough for assistance if they go apneic...

I would recommend never using an LMA for a surgery if this is the case. Should always be able to rescue a patient with manual bag ventilation.

 

[deleted697127]

I would recommend never using an LMA for a surgery if this is the case. Should always be able to rescue a patient with manual bag ventilation.

Lol. Gee thanks. This is the kind of advice residents go talk @$C*% about in the lounge. Your recommendation is to never have an LMA fail? What exactly do you think happened after what I’m referring to, you think patient just desats and dies?

 

[deleted697535]

10mg of roc makes every lma sit like a dream

 

[deleted875186]

Lol. Gee thanks. This is the kind of advice residents go talk @$C*% about in the lounge. Your recommendation is to never have an LMA fail? What exactly do you think happened after what I’m referring to, you think patient just desats and dies?

Lol, didn’t mean to be a jerk.

I had one attending in residency that refused to change an LMA that didn’t sit well enough to bag the patient easily because the LMA would “work fine with spontaneous ventilation”. Refused to let me change it. Only problem was the case was a vitrectomy, bed was turned and airway away from me, attending left and let me worry about it. Luckily didn’t have to assist or bag the lady for that one hour.

Had that type of case on my mind, agree LMAs that once sat well can fail during a case.

 

[GassYous]

Lol. Gee thanks. This is the kind of advice residents go talk @$C*% about in the lounge. Your recommendation is to never have an LMA fail? What exactly do you think happened after what I’m referring to, you think patient just desats and dies?

I think you took his words and tone in the wrong way. I kinda agree with him. I don't like it when lmas don't sit well and I'd rather just paralyze, pull and tube for the peace of mind rather than sit with an lma that I can't bag with. This is especially true for field avoidance cases like shoulders. I don't want to undrape, reposition, redrape blah blah blah. It's just a pain in the butt.

 

[Volatile]

In residency I loved LMA’s, probably pushed to use them when I shouldn’t have. Now that I’ve been out practicing for a few years I find myself using them less and less for the above reasons. I never regret an ETT.... definitely have w/ LMA’s. If I am losing the head, they pretty much always get an ETT now.

 

[deleted171991]

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

Because fentanyl is better than versed at sedating elderly.

 

[Velefunt]

Some day I’ll learn to not give 50 of fent when the patient moves a little with an Lma that works for spontaneous ventilation but doesn’t seat well enough for assistance if they go apneic...

I've learned to give 25mcg at a time during spont vent LMA, cause 50mcg def burns you most of the time.

 

[Velefunt]

In residency I loved LMA’s, probably pushed to use them when I shouldn’t have. Now that I’ve been out practicing for a few years I find myself using them less and less for the above reasons. I never regret an ETT.... definitely have w/ LMA’s. If I am losing the head, they pretty much always get an ETT now.

I'd be interested to see if you change after an additional few years or change jobs; I found that my first many years in PP I did the same as you. Then after a job change and new work environment, I went back to LMAs. I also became more "adventurous" (for me and my training) with LMA's - lateral positioning, sinus surgeries, bronchoscopies, flirted w/ sitting position and turned away from me, removing "deep," using in morbid and super morbidly obese and even administering the exceedingly rare small NMB dose per surgeon request, due to surgical need. The only thing I still consistently don't do is positive pressure ventilate with one; If I need to breathe for you consistently, I'm going to intubate you.

 

[deleted171991]

I'd be interested to see if you change after an additional few years or change jobs; I found that my first many years in PP I did the same as you. Then after a job change and new work environment, I went back to LMAs. I also became more "adventurous" (for me and my training) with LMA's - lateral positioning, sinus surgeries, bronchoscopies, flirted w/ sitting position and turned away from me, removing "deep," using in morbid and super morbidly obese and even administering the exceedingly rare small NMB dose per surgeon request, due to surgical need. The only thing I still consistently don't do is positive pressure ventilate with one; If I need to breathe for you consistently, I'm going to intubate you.

If you want to try controlled ventilation, use Supreme LMAs until you get comfortable with the idea.

Nothing teaches one how to properly fit an LMA (and the safety limits of an LMA) like controlled ventilation.

 

[GassYous]

I'd be interested to see if you change after an additional few years or change jobs; I found that my first many years in PP I did the same as you. Then after a job change and new work environment, I went back to LMAs. I also became more "adventurous" (for me and my training) with LMA's - lateral positioning, sinus surgeries, bronchoscopies, flirted w/ sitting position and turned away from me, removing "deep," using in morbid and super morbidly obese and even administering the exceedingly rare small NMB dose per surgeon request, due to surgical need. The only thing I still consistently don't do is positive pressure ventilate with one; If I need to breathe for you consistently, I'm going to intubate you.

I do all of these things except the super morbidly obese. I know they can do okay with an lma but I still tube them all.

 

[nimbus]

If you want to try controlled ventilation, use Supreme LMAs until you get comfortable with the idea.

Nothing teaches one how to properly fit an LMA (and the safety limits of an LMA) like controlled ventilation.

I paralyze and do controlled ventilation all the time with the Unique.

 

[deleted697535]

I paralyze and do controlled ventilation all the time with the Unique.

Same.works great basically always. Did one for 130kg dude last week. 2 hiur case

 

[Velefunt]

I paralyze and do controlled ventilation all the time with the Unique.

Evidently amongst many of my newer generation of workmates, the i-Gel is the cat's pajamas. I remember using the "prototype" back when and nobody liked them; I'm still leery. I'll give you my silicone reusable LMA, when you pry it from my cold, dead hands... though I DO like an LMA Supreme once in a while for them toothless fellers.

 

[ToKingdomCome]

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

I over shot yesterday and had to give narcan to patient in pacu for giving too much opioid intra op. Feels bad. How often are you guys over shooting ?

 

[pocafx]

Twice in residency. 3 months left. Last week Gave 50 fent to restless, patient in pacu. Called 5 mins later to bag her. Waved Narcan n in front of patient and started breathing again. 5 minutes later. moaning in pain. So actually once but cracked the vial twice.

 

[GassYous]

I over shot yesterday and had to give narcan to patient in pacu for giving too much opioid intra op. Feels bad. How often are you guys over shooting ?

I've given narcan twice in the OR in the past few years.. No biggie, it happens.

 

[Hork Bajir]

If you’re not giving Narcan every once in a while, probably means you’re not giving enough opioid

…cue the angry chorus of opioid sparing zealots ;D

 

[Hoya11]

I over shot yesterday and had to give narcan to patient in pacu for giving too much opioid intra op. Feels bad. How often are you guys over shooting ?

get them breathing on the vent spontaneously before extubation, titrate additional opiates or narcan at that time, you should know whether you undershoot or overshoot before PACU. As you do it more and more, you overshoot less and less - or at least you dont overshoot to the point of apnea requiring narcan. Most I deal with is nausea and I do feel bad but id rather nausea in some than pain for all. Most overshooting I see happening with fentnayl boluses rather that something less acute acting like dilaudid (which is going to help them more anyway in PACU)

 

[ToKingdomCome]

get them breathing on the vent spontaneously before extubation, titrate additional opiates or narcan at that time, you should know whether you undershoot or overshoot before PACU. As you do it more and more, you overshoot less and less - or at least you dont overshoot to the point of apnea requiring narcan. Most I deal with is nausea and I do feel bad but id rather nausea in some than pain for all. Most overshooting I see happening with fentnayl boluses rather that something less acute acting like dilaudid (which is going to help them more anyway in PACU)

For a very long robotic case what’s your narcotic goals and how much do you titrate? Front load everything? Or give through out.

 

[DrOwnage]

For a very long robotic case what’s your narcotic goals and how much do you titrate? Front load everything? Or give through out.

Need more info to answer this question. Type of robotic surgery? Patient age, history, chronic use of opioids? Can you do a block? All of these questions would affect my approach. Typically in a long case I would not be giving lots of long acting opiates throughout unless neuromuscular blockade was contraindicated. Its sometimes easy to overshoot depending on patient sensitivity if you're using them for immobility/depth of anesthesia. The most consistent method in my opinion is to see what the patient is doing on the vent 15 minutes prior to extubation with a moderate dose of opioid given a little bit prior to that (0.5-1mg for a painful procedure). If they're still breathing faster than 14 or 15 on PSV or on the bag you most likely underdosed them and will have time for dilaudid to make them more comfortable when they wake up. I find a pretty consistent connection between RR or ETCO2 while the patient is intubated and their comfort level when they wake up in PACU.

 

[Hoya11]

For a very long robotic case what’s your narcotic goals and how much do you titrate? Front load everything? Or give through out.

its not that simple and cookie cutter. what i found helpful for students is to have them draw a "pain curve" of the surgery and PACU stay, and try to match your opiate plasma level to that pain curve.

Most surgeries, there is intense pain in the beginning, a period of stability where there is less pain, and then more intense pain again at the end and into PACU. Sounds simple, but you want to give more coverage during the painful periods, dont give unnecessarily during the stable periods, and then give at the end when you can titrate to respiratory rate. If im giving more than 200 of fent, im also mixing in dilaudid.

Say we are talking about a radical prostate robotic on an otherwise healthy 50 year old 70kg man.

I would think hes going to get 100 of fent on induction, 2mg dilaudid throughout the case at least. Maybe 1 up front, 0.5 mid case PRN, and another 0.5 on wake up.

 

[zizzer]

I over shot yesterday and had to give narcan to patient in pacu for giving too much opioid intra op. Feels bad. How often are you guys over shooting ?

Why feel bad? Did you give a whole 0.4mg naloxone or something? You can dilute it and titrate in 40-80mcg at at time without taking away all the analgesic effect.

 

[DrN2O]

My fentanyl dosing comes in fixed 100/250/500mcg aliquots. And most of times the 50-100 fentanyl residents give on induction is a waste.

 

[deleted875186]

I disagree, I find 50 mcg fentanyl on induction and 50 mcg for incision is more than enough. I will often induce without fentanyl on older people. For most cases i rarely have a need to give 250 mcg, and as stated above, if it’s that stimulating then perhaps just move on to long acting opioids.

 

[ToKingdomCome]

Why feel bad? Did you give a whole 0.4mg naloxone or something? You can dilute it and titrate in 40-80mcg at at time without taking away all the analgesic effect.

I feel bad that I overshot and had a poor analgesic plan leading me to have to give narcan (diluted)

 

[DocVapor]

I feel bad that I overshot and had a poor analgesic plan leading me to have to give narcan (diluted)

Anesthesia is as much an art as a science, and there will always be a patient that surprises you. As long as you use one hand's fingers to count the number of times you've given narcan due to your own actions, you're doing pretty well.

 

[deleted875186]

I feel bad that I overshot and had a poor analgesic plan leading me to have to give narcan (diluted)

Who cares …. So you gave some narcan, patient is awake, narcan wears off in 30 mins, they are monitored in PACU, no harm done.

 

[ToKingdomCome]

Anesthesia is as much an art as a science, and there will always be a patient that surprises you. As long as you use one hand's fingers to count the number of times you've given narcan due to your own actions, you're doing pretty well.

Thanks I appreciate it. Im a senior resident tho and I’m pretty sure my attending thought I was a dumb idiot for the amount of narcotic I gave which feels bad but like you said, oh well, shi* happens

 

[zizzer]

Attendings often think you're a dumb idiot for various choices, but they're not always right. I don't think having to give some naloxone is the worst thing in the world like some people act like it is. There can be downsides or even harm in some situations to not enough narcotic, for example on cases where a smooth emergence is desirable.