Intraop analgesia

[nimbus]

We recently got fentanyl in 50mcg prefilled syringes. I love them as it leads to much less waste. I wish we had hydromorphone in vials smaller than 2mg. Has anybody seen them? 2mg is too much for most patients and procedures, and it’s a pain to waste opioids.

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[Hoya11]

We recently got fentanyl in 50mcg prefilled syringes. I love them as it leads to much less waste. I wish we had hydromorphone in vials smaller than 2mg. Has anybody seen them? 2mg is too much for most patients and procedures, and it’s a pain to waste opioids.

Yes we have got them in 0.5 which are great

 

[DocVapor]

We recently got fentanyl in 50mcg prefilled syringes. I love them as it leads to much less waste. I wish we had hydromorphone in vials smaller than 2mg. Has anybody seen them? 2mg is too much for most patients and procedures, and it’s a pain to waste opioids.

We have 1 mg prefilled syringes. It's great until the pharmacy swaps them out for 2 mg prefilled syringes without warning anyone.

 

[nimbus]

We have 1 mg prefilled syringes. It's great until the pharmacy swaps them out for 2 mg prefilled syringes without warning anyone.

Yeah our pharmacy used to give us 0.5mg/ml duramorph but they switched us to 1mg/ml to keep us on our toes

 

[DocVapor]

Yeah our pharmacy used to give us 0.5mg/ml duramorph but they switched us to 1mg/ml to keep us on our toes

Pharmacy games are the BEST games!

 

[Gasmd98]

Some complicated anesthetics here for a simple case. Acetaminophen 1gm PO in preop. Fentanyl 1 mcg/kg preinduction and repeat post intubation and during case as indicated. 10 mcg/kg hydromorphone once fascia closed plus 15 mg ketotolac. Maybe another 0.2 mg hydromorphone before leaving OR if needed. Give report to PACU nurse and close chart. Why make life complicated? If the patient acts a little goofy in PACU which of the many drugs is the cause? Why make your controlled drug reconciliation at the end an ordeal? I just want to land the plane in the middle of the runway, not do acrobatics. Now, if we are talking a big 10 hour spine case I am all over all of the suggestions by others.

 

[Planktonmd]

So... it' s very nice to be one of these opioid sparing champions and to follow these complicated plans like the ones
amateurs like blade would tell people to do... but at the end of the day, there is absolutely no problem with using opiates or whatever you you need for surgical anesthesia.
Please ignore people like blade and others who actually think that anesthesia is an exact science.

 

[Arch Guillotti]

Some complicated anesthetics here for a simple case. Acetaminophen 1gm PO in preop. Fentanyl 1 mcg/kg preinduction and repeat post intubation and during case as indicated. 10 mcg/kg hydromorphone once fascia closed plus 15 mg ketotolac. Maybe another 0.2 mg hydromorphone before leaving OR if needed. Give report to PACU nurse and close chart. Why make life complicated? If the patient acts a little goofy in PACU which of the many drugs is the cause? Why make your controlled drug reconciliation at the end an ordeal? I just want to land the plane in the middle of the runway, not do acrobatics. Now, if we are talking a big 10 hour spine case I am all over all of the suggestions by others.

No offense but I think cookbook opiod dosing makes things complicated.

 

[Hork Bajir]

I was thinking about this thread yesterday when I took over a case from one of my partners- young otherwise healthy woman having a big cancer whack. Epidural placed pre-op and demonstrated to have a level before going to sleep, then used the whole case.

I come in for emergence, and find the CRNA with someone I don’t recognize, who introduces herself to me as a “senior SRNA”. Patient is taking her sweet time to wake up, eventually opens her eyes and starts looking around at us but doesn’t want to breathe… I ask how much narcotic she’s gotten.

500 of Fentanyl and 2mg hydromorphone. Not sure if I did a good job masking my facial expression when I heard that… Took 160mcg of Narcan in divided doses until the lady started breathing (with a RR of 7).

FML. In that case, the “senior” SRNA must have been following some cookbook I’ve never heard of…

 

[2Fast2Des]

I was thinking about this thread yesterday when I took over a case from one of my partners- young otherwise healthy woman having a big cancer whack. Epidural placed pre-op and demonstrated to have a level before going to sleep, then used the whole case.

I come in for emergence, and find the CRNA with someone I don’t recognize, who introduces herself to me as a “senior SRNA”. Patient is taking her sweet time to wake up, eventually opens her eyes and starts looking around at us but doesn’t want to breathe… I ask how much narcotic she’s gotten.

500 of Fentanyl and 2mg hydromorphone. Not sure if I did a good job masking my facial expression when I heard that… Took 160mcg of Narcan in divided doses until the lady started breathing (with a RR of 7).

FML. In that case, the “senior” SRNA must have been following some cookbook I’ve never heard of…

Senior stupid, who and what do they learn from... Christ, even a green CA1 wouldn't do something that stupid

 

[UscGhost]

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 had an attending who believed that we didn't need to give opiods intraop because patients don't "feel pain" under anesthesia...during major surgical procedures.

The patients just ended up screaming as soon as they got to pacu once the sevo wore off.

He was fired after a few weeks of that.

Just give fentanyl along with the multimodal and titrate to comfort.

 

[nimbus]

I was thinking about this thread yesterday when I took over a case from one of my partners- young otherwise healthy woman having a big cancer whack. Epidural placed pre-op and demonstrated to have a level before going to sleep, then used the whole case.

I come in for emergence, and find the CRNA with someone I don’t recognize, who introduces herself to me as a “senior SRNA”. Patient is taking her sweet time to wake up, eventually opens her eyes and starts looking around at us but doesn’t want to breathe… I ask how much narcotic she’s gotten.

500 of Fentanyl and 2mg hydromorphone. Not sure if I did a good job masking my facial expression when I heard that… Took 160mcg of Narcan in divided doses until the lady started breathing (with a RR of 7).

FML. In that case, the “senior” SRNA must have been following some cookbook I’ve never heard of…

I’ve never liked or been impressed by a single human who introduced themselves as “senior blah blah blah”. However, I am fond of gray muzzled senior dogs.

 

[GassYous]

I’ve never liked or been impressed by a single human who introduced themselves as “senior blah blah blah”. However, I am fond of gray muzzled senior dogs.

It's like when people introduce themselves as "doctor" whatever. Last one I had was a vet. Call yourself whatever you want but medical doctors never seem to need to do that.

 

[deleted875186]

I had an attending who believed that we didn't need to give opiods intraop because patients don't "feel pain" under anesthesia...during major surgical procedures.

The patients just ended up screaming as soon as they got to pacu once the sevo wore off.

He was fired after a few weeks of that.

Just give fentanyl along with the multimodal and titrate to comfort.

I agree with them, yoo don’t need opioids while under GA, but you still need a plan for when they wake up. For most of us it’s tylenol, NSAID, and a small dose of hydromorphone, but could also be TAP block, local at port sites or exparel infiltrated by the surgeon, or a joint cocktail injected by a surgeon, etc.