OIH remi vs fent

[turnupthevapor]

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I understand Remi increases the risk of opioid-induced hyperalgesia after spine surgery. My question is is this more prominent with remi vs sufenta/fentanyl or is it a class effect?

thank you

 

[Planktonmd]

I understand Remi increases the risk of opioid-induced hyperalgesia after spine surgery. My question is is this more prominent with remi vs sufenta/fentanyl or is it a class effect?

thank you

All opiates cause dose dependent hyperalgesia, and since Remi has a very short half life, that hyperalgesia becomes more noticeable postop than with other longer acting opiates that produce some residual analgesia post-op.

 

[deleted162650]

I think part of the problem with Remi is that since it has a dose/context-independent 1/2 life people are tempted to really crank up the dosing which exacerbates the problem. If you keep the dosing to something reasonable like 0.2 then I don't think it's much of a problem. I'm not personally a big Remi fan though. I think it's a great drug for people who aren't very good at anesthesia (but that's probably just me being an elitist 😀).

 

[OB1🤙]

I haven't used remi in about 4 years, because of the hyperalgesia issue.

There was some recent stuff on this, too busy to look up at the moment, but my recollection is that yes, the issue is demonstrably worse with remi.

 

[pgg]

There's a study in Feb's issue of Anesthesiology about fentanyl and OIH. I didn't think it was a very useful study because it used doses totally irrelevant to modern anesthesia (10 mcg/kg), and their simultaneous one arm in a bucket of ice + electric shocks to the other arm methodology was wack, but AFAIK there's not much else out there about fentanyl OIH in humans.

My bet is that there's no magic or subtlety to any of it, that it's dose and potency and duration and pre-existing exposure/tolerance related. Remi is super potent and people can overuse it without obvious penalty, so it has the worst OIH reputation. But I don't think the data is there to really compare the different fents to each other in equipotent doses.

It's a hard thing to study. The difference between "patient hurts because of OIH" and "patient hurts because he needs more narcotic" is hard to tease out, and the treatment is basically going to be the same in PACU anyway.


Me, I believe OIH is a real thing, and clinically significant, so I minimize opiate use under GA, try not to miss a chance to add adjuncts (esp ketamine), and use a lot of esmolol to keep hemodynamics where I want them, and tack on something from a blue syringe at the end so they don't wake up hurting. It seems to work.

 

[dhb]

I think it's more noticiable with remi because of overdosage in the context of a short half life.
I only use it to intubate when i don't want to use a muscle relaxant.

 

[Jimmy Chitwood]

A little ketamine goes a long way

 

[Random Anesthesiologist]

A little ketamine goes a long way

Sometimes use remi but always with ketamine.

 

[agammaglobulin]

I understand Remi increases the risk of opioid-induced hyperalgesia after spine surgery. My question is is this more prominent with remi vs sufenta/fentanyl or is it a class effect?

thank you

I add adjuncts to reduce the dose of Remi you are running during the case (0.2ish vs 0.4ish). I always run Ketamine and have been trying low dose Methadone (10-20mg) after induction in spine cases which reduces both Remi dose and post op pain scores without any additional resp depression.

 

[vector2]

BMC Anesthesiol. 2015; 15: 21.
Published online 2015 Feb 24. doi: 10.1186/s12871-015-0004-1
PMCID: PMC4352285
Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study
Wonjung Hwang, Jaemin Lee, Jihyun Park, and Jin Joo

Background
Total intravenous anesthesia (TIVA) is used widely in spinal surgery because inhalational anesthetics are known to decrease the amplitude of motor evoked potentials. Presently, dexmedetomidine is used as an adjuvant for propofol-based TIVA. We compared the effects of remifentanil and dexmedetomidine on pain intensity as well as the analgesic requirements after post-anesthesia care unit (PACU) discharge in patients undergoing spinal surgery.

Methods
Forty patients scheduled for posterior lumbar interbody fusion (PLIF) surgery under general anesthesia were enrolled. Anesthesia was maintained using propofol at 3–12 mg/kg/h and remifentanil at 0.01–0.2 μg/kg/min in Remifentanil group or dexmedetomidine at 0.01–0.02 μg/kg/min in Dexmedetomidine group, keeping the bispectral index between 40 and 60. Patient-controlled analgesia (PCA) made of hydromophone was applied once the patients opened their eyes in the PACU. The visual analog scale (VAS) score, PCA dosage administered, and postoperative nausea and vomiting (PONV) were recorded at the time of discharge from the PACU (T1) and at 2 (T2), 8 (T3), 24 (T4), and 48 hours (T5) after surgery.

Results
The VAS score in Remifentanil group was significantly higher than that in Dexmedetomidine group at immediate and late postoperative period (4.1 ± 2.0 vs. 2.3 ± 2.2 at T1, and 4.0 ± 2.2 vs. 2.6 ± 1.7 at T5; P < 0.05). Dexmedtomidine group had a statistically significantly lower PCA requirement at every time point after surgery except directly before discharge from the PACU (3.0 ± 1.2 ml vs. 2.3 ± 1.4 ml at T1; P > 0.05, but 69.7 ± 21.4 ml vs. 52.8 ± 10.8 ml at T5; P < 0.05). Patients in Remifentanil group displayed more PONV until 24 hours post-surgery.

Conclusions

Dexmedetomidine displayed superior efficacy in alleviating pain and in postoperative pain management for 48 hours after PLIF. Therefore, dexmedetomidine may be used instead of remifentanil as an adjuvant in propofol-based TIVA.

 

[deleted59964]

I use remi for stimulating procedures that are not very painful post operatively
Pinning in neurosurgery is one example
for Fess it gives great conditions for surgery

Bit of fentanyl at the end and the patients are fine in recovery.
Whether it causes oih or just acute tolerance I'm not sure, but I believe remi has its place, and is very useful when used correctly for the right indications.

 

[Planktonmd]

I think it's more noticiable with remi because of overdosage in the context of a short half life.
I only use it to intubate when i don't want to use a muscle relaxant.

Remi gives you muscle relaxation for intubation???

 

[deleted162650]

Never used Remi for that but I have done it with alfentanil a handful of times which works surprisingly well.

 

[OB1🤙]

I think alfentanil is the most under-utilized drug in our armamentarium.

 

[fakin' the funk]

I think alfentanil is the most under-utilized drug in our armamentarium.

I agree it's a useful drug. It's also used zero in my armamentarium currently, because my hospital system doesn't have it.

 

[pgg]

I think alfentanil is the most under-utilized drug in our armamentarium.

Unfortunately not in our supply chain. I haven't seen it in 3 or 4 years.

 

[PainDrain]

Remi is great for certain cases, cranis with pinning and cases that are briefly extremely stimulating. I don't see its utility in most situations.

Precedex is another story. That drug is amazing and can seriously cut down on opiate requirements in many different circumstances. I have used it for everything from pedi to cranis to ENT procedures.

As for OIH, in my chronic pain experience I have noticed patients on fentanyl TD tend to have more issues with hyperalgesia compared to other chronic opiates. It's anecdotal but I definitely see a relationship.

 

[OB1🤙]

I think the remi marketers have done an amazing job over the years convincing hospitals to use it rather than alfenta.

Whatever you want to do with remi, I can do with alfenta.

Glad we still have it. Even here, I think I'm one of maybe 3 people in a huge department that ever use it.

 

[seinfeld]

I receive a report every month of narcan use in my hospital. Interestingly the non-anesthesia physicians on the group were concerned that so many of the narcan uses were associated with the intra-op use of Remi. Although they did not understand how remi actually worked, I have my suspicions that the OIH "wears off" and leaves the patient vulnerable to opioid sensitivity latter on. My other theory is that these same patient are getting medicated for the sleeping 10's. However our PACU uses the POSS scale which incorporates how the patient looks and acts as much as a 0-10 pain scale.

 

[dhb]

Remi gives you muscle relaxation for intubation???

Very high quality
Alfentanil? Don't really see the use for it.

 

[narcusprince]

In training for peripheral procedures in the asc we use prop/alfenta and it worked excellant. Allowed us to get away without using an lma. Needle localizations/ plastics cases all done w prop/alfenta.

 

[Hoya11]

The OPs question makes me think they do not understand what OIH is. Actually, I dont relieve believe in OIH. I just believe people get tolerant. Hard to prove the difference. Anyways, when I do think about OIH, its in the situation of someone on CHRONIC narcotics, the system rewires similar to wind up and hyperalgesia ensues. I can kind of see this, but again doubt it and think most cases are just tolerance. The idea that giving remifentanil or fentanyl perioperatively will cause any degree of OIH to me doesnt make sense. The people waking up from the procedure complaining of pain have LACK of opiate on board and true pain, not OIH. So give them more, and dont think about this feeble stuff that is mostly academic BS.

 

[Airlife91]

Never used Remi for that but I have done it with alfentanil a handful of times which works surprisingly well.

How are you using the alfentanil - bolus, infusion, both? What are your doses? I've used it often as a bolus for short stimulating procedures under MAC - i.e. 200-300mcg before the surgeon injects local, or a bigger dose prior to DL. Never run an infusion, so not sure how to dose it.

 

[propadope]

Remi gives you muscle relaxation for intubation???

Not muscle relaxation. But combined with propofol you can get pretty good intubation conditions. No movement, no cough, cords open, apnea etc...

 

[propadope]

Not muscle relaxation. But combined with propofol you can get pretty good intubation conditions. No movement, no cough, cords open, apnea etc...

Of course if you give too much too fast the cords are gonna be closed and you won't be able to ventilate. Obviously NOT good intubating conditions. There is an art to it...

 

[deleted162650]

Alfentanil 30/kg plus your usual dose of induction agent. Essentially replacing sux with alfenta. Works very well. There's a paper or two which compare alfenta to sux and intubating conditions are near identical. My shop doesn't carry alfenta either 🙁. They actually don't carry sufenta either which I miss even more. Prop/sufenta gtt's are great for spines with neuromonitoring.

 

[deleted162650]

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