Sufentanil & Methadone

[Airlife91]

How are you guys using Sufentanil these days? Long Spines...neuro....cardiac...other things?
How do you like to dose it? Bolus? Infusion?

I haven't used it much since training. In residency, we used it mostly for long spine and neuro cases. With those long cases I got pretty comfortable with timing of the infusions to not delay any wake-ups. We didn't use it much in other cases. Most cases in PP have been so much faster that I have been hesitant to use it.

How about Methadone? I never used it in training because it was either unavailable and/or nobody wanted to use it. However now it seems to have some promising data for use in both neuro and cardiac cases and I'd like to start using it in both. Same question - how do you like to dose it? Bolus? Infusion? I read a 2015 study supporting 0.2mg/kg at induction for cardiac cases (Anesthesiology 2015; 122:1112-22).

Thanks for any input!

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[sevoflurane]

Used to burn through 100 mcgs of sufenta for hearts. I’m back to fentanyl.

I do use methadone quite a bit. Fairly good data for hearts. 10ish mg on average.
Try not to go over 15mg.
Same for spines.

 

[sevoflurane]

I bolus methadone up front.

 

[dhb]

MIA: minimal infusion anesthesia
For hearts i set up a infusion with 2mcg sufenta & 5mg ketamine/cc and run it a 2cc/h before sternotomy then i would decrease to 1.5 or 1cc/h.
End up giving 25mcg or less.
I don't do long spine cases but i would use the same approach.

 

[nimbus]

Speaking of sufentanil.....

F.D.A. Approves Powerful New Opioid Despite Warnings of Likely Abuse

Every opioid should be available in an easy to use, outpatient formulation

 

[facted]

I used methadone for big whacks. .15 - .2 mg/kg up front, usually limit it to 20mg. Bolus up front. Onset is 10 minutes. The issue with it is the half life is extremely variable and you can have an effect greater than 48 hrs. May handcuff acute pain management on the floor.

 

[Airlife91]

I used methadone for big whacks. .15 - .2 mg/kg up front, usually limit it to 20mg. Bolus up front. Onset is 10 minutes. The issue with it is the half life is extremely variable and you can have an effect greater than 48 hrs. May handcuff acute pain management on the floor.

For your bolus, are you just bolusing it by hand or loading it over a certain amount of time (ie dexemedatomidine load over 10min)?

 

[facted]

For your bolus, are you just bolusing it by hand or loading it over a certain amount of time (ie dexemedatomidine load over 10min)?

Bolus is fine, never had an issue. Sometimes I it hand bolus over 2 or 3 minutes but I don't really know why haha.

 

[narcusprince]

With the methadone do you give other narcotics? Methadone and Remi or just methadone and no other narcs?

 

[partydoc]

With the methadone do you give other narcotics? Methadone and Remi or just methadone and no other narcs?

I'll suppliment the methadone intraop with fent or sufenta.

 

[ethilo]

I've been using methadone more and more lately, trying to incorporate it into my practice. I dug through some papers and made some notes for myself. Here's fresh out of my personal notes:

Murphy G, et al. "Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery." Anesthesiology 5 2017, Vol.126, 822-833. doi:10.1097/ALN.0000000000001609

• In patients undergoing posterior spinal fusion surgery (averaging two levels), intravenous methadone (0.2mg/kg actual body weight) given at induction compared with intravenous hydromorphone (2mg at surgical closure) resulted in decreased postoperative intravenous and oral opioid requirements and also diminished pain scores and improved patient satisfaction

Murphy G, et al. "Intraoperative Methadone for the Prevention of Postoperative Pain: A Randomized, Double-blinded Clinical Trial in Cardiac Surgical Patients" Anesthesiology 5 2015, Vol.122, 1112-1122. doi:10.1097/ALN.000000000000063.

• When administered at larger doses (20 to 30 mg), the duration of analgesia is ≈24 to 36 h. Therefore, a single administration at induction of anesthesia may provide stable analgesia throughout the ICU admission (which corresponds to the time of highest reported pain scores). When used at doses of 0.2 to 0.3 mg/kg, methadone has not been associated with a higher incidence of opioid-related adverse events (compared with shorter-acting opioids).

Kharasch, E. "Intraoperative methadone: Rediscovery, reappraisal, and reinvigoration?" Anesth Analg. 2011 January ; 112(1): 13–16. doi:10.1213/ANE.0b013e3181fec9a3.

• Targeting doses and concentrations as high as possible above the minimal analgesic concentration, but below the threshold for respiratory depression, will achieve the longest-lasting analgesia. At concentrations approximately ≥20 mg, the duration of methadone analgesia approximates its elimination half life.
• Liver CYPs metabolize methadone to inactivate the drug and may be less susceptible to inhibitory drug interactions than previously thought. Methadone is considered to have a highly variable clearance.
• A single 20 mg intravenous bolus dose is administered before induction. This is reduced to 15 mg in patients “physiologically” older than 60 yr, because of declining methadone elimination and increased risk of respiratory depression with age.
• For postoperative analgesia, intravenous methadone (2-3 mg doses at >10 min intervals) is administered in the post-anesthesia care unit as needed, if a patient complains of pain and has an unstimulated respiratory rate greater than 10.

 

[ethilo]

The way I've been tending to use it is 0.2 mg/kg up front bolus, then fentanyl just for intubation and wait and see how it goes in the OR, usually just an extra fentanyl here or there. I was actually quite surprised to see that when you bolus it in the person while they are still awake and watch its effects, they do actually start to get affected by it rather quickly, like in a couple minutes. It's faster on than morphine but slower on than fentanyl from my experience. But not really all THAT much slower on than fentanyl actually.

For chronic pain opioid tolerant people getting redo spine surgery I'll do 0.5 mg/kg ketamine as well as methadone 0.2 mg/kg actual body weight. I think the more you can do of pre-emptive analgesia, and managing the gate theory of pain in these chronic pain rev'd up spine cases, the better.

Peak effect of respiratory depression is around 60-80 mins with methadone from what I remember reading.

 

[anbuitachi]

how are you guys dosing JUST methadone as intraop narc? how often do you redose? 4-6 hours?