Midazolam vs. Fentanyl
Started by refreshingred
ask them to defend their statement with some evidence base. they're the one making the claim (ie, tell them to point you to a study). benzos on the whole have far less effects on respiratory drive than do the opiates. and it is still highly patient-dependent.
in the meantime, you can read this
http://pediatrics.aappublications.org/cgi/content/full/102/4/956
which suggests that the fentanyl is the real culprit in respiratory depression, not the midazolam, or at least there is strong synergy between the fentanyl/midaz combo. in other words, midaz may cause respiratory depression whereas fentanyl certainly will. who knows at those doses though. i've pushed 2mgs of midaz on plenty of patients as well as 50mcgs of fentanyl without any clear cut effects either way and a still lot of interpatient variability. neither of those doses are by themselves very big. so i think your attending is making a statement based on personal observation and experience that can't really be defended. and that's not really what modern day EBM is all about, is it?
in the meantime, you can read this
http://pediatrics.aappublications.org/cgi/content/full/102/4/956
which suggests that the fentanyl is the real culprit in respiratory depression, not the midazolam, or at least there is strong synergy between the fentanyl/midaz combo. in other words, midaz may cause respiratory depression whereas fentanyl certainly will. who knows at those doses though. i've pushed 2mgs of midaz on plenty of patients as well as 50mcgs of fentanyl without any clear cut effects either way and a still lot of interpatient variability. neither of those doses are by themselves very big. so i think your attending is making a statement based on personal observation and experience that can't really be defended. and that's not really what modern day EBM is all about, is it?
Crank out the old CO2 depression curves and take a look. Opioids, by themselves, are strong respiratory depressors. For example when we are doing LMA cases and the pt is breathing 30 we reach for the fentanyl (sometimes all it takes is 10 mcg) to drop their drive. Just watch the CO2 build up before the start breathing. Neat stuff.
In elderly people things change and I would hesistate to give them 2mg of versed up front because of respiratory depression. Benzo's plus opioids can severly drop both cardiovascular and respiratory paramaters. Danger will robinson.
In elderly people things change and I would hesistate to give them 2mg of versed up front because of respiratory depression. Benzo's plus opioids can severly drop both cardiovascular and respiratory paramaters. Danger will robinson.
havent formerly done my Anesthesiology rotation but have extensively shadowed w/o too much extensive "why'd u do that" yet. But on many ocassions, I've drawn up both fentanyl and versed for a pt in prep for the intub. IF my memory serves me correctly (and yes I know i need to now be more vigilant) versed was given initially, and fenty prn.
So...since they're both given almost at the same time, I'm wondering how the OP's attending new which produced the dec in resp. 😎
So...since they're both given almost at the same time, I'm wondering how the OP's attending new which produced the dec in resp. 😎
You can do your own study on this if you wish. Just like Vent. was saying when using an LMA you can really slow down the RR with Fentanyl. But better yet, do a couple of cases with an LMA. Give versed (2 mg) and propofol and see how long it takes the pt. to start breathing. Then do the same with fentanyl (50 mcg) and propofol. You will see the difference for sure. But the best advice here was given by Volatile. Ask your attending to back it up, but you must be politically correct when asking ( Dr. soandso could you point me in the direction of that study; is a good start).
