why use suf?

[deleted697535]

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Suf is a new drug for me this side of the pond, and I dont really know its place. The cardiac ppl here love it, can anyone explain why?

It's slower onset than fent by 2 to 3 mins so for induction I wonder about its place. and still has a csht that becomes significant after about 4 to 5 hours so infusion is an issue too.

I Googled and saw some studies about fast track cardiac outcomes. Anyone any more info?
Thanks

 

[ethilo]

We used it a lot in my residency as part of TIVA instead of remi because it was a lot cheaper and similar CSHT to propofol. The idea was you could just turn the 2 off together. My personal way of doing endonasal sinus surgery for pituitary tumor excision used a high rate of su (like 0.5 mcg/kg/h) for about an hour during the ENT dissection then eventually back off to 0.1 mcg/kg/h post resection and beginning of closure. Seemed to work really well for that.

We also had sufenta in our labor epidural solutions, I think it was bupi 0.055% + 1 or 2 mcg/mL sufenta. Ladies loved it!

 

[deleted875186]

Suf is a new drug for me this side of the pond, and I dont really know its place. The cardiac ppl here love it, can anyone explain why?

It's slower onset than fent by 2 to 3 mins so for induction I wonder about its place. and still has a csht that becomes significant after about 4 to 5 hours so infusion is an issue too.

I Googled and saw some studies about fast track cardiac outcomes. Anyone any more info?
Thanks

I would disagree with the slower onset than fentanyl. Fentanyl takes 5 min or more to reach full effect, sufentanyl is more like a couple minutes. I think of it as similar to Remi in short cases, but more of a tail for prolonged infusions. Its CSHL is much more favorable than fentanyl after several hours. I think it’s better than Remi for any case that has postoperative pain, for instance any spine case with neuromonitoring. I think it works well for VATS as well. We don’t do fast track cardiac at my hospital, but I imagine it works well for that as well.

 

[Section31]

It’s just more potent fentanyl. If you want to give ultra-large doses of narcotic, for example for cardiac-stable narcotic induction, it’s easier.

 

[abolt18]

It’s just more potent fentanyl. If you want to give ultra-large doses of narcotic, for example for cardiac-stable narcotic induction, it’s easier.

Have an attending who will give like 500mcg in induction then run low iso and nothing else the rest of the case. Tends to last through the case in into the first couple hours in the ICU in my experience.

 

[psychbender]

Have an attending who will give like 500mcg in induction then run low iso and nothing else the rest of the case. Tends to last through the case in into the first couple hours in the ICU in my experience.

500mcg of sufenta? Damn, that's a heavy hand. I rarely use more than 500mcg of fentanyl for a regular pump case. One place through which I roasted in residency used sufenta for cardiac cases, and the average there was still 50-150mcg per case (usually split a 250mcg vial between two cases, with a touch left to return to Pharmacy).

 

[abolt18]

500mcg of sufenta? Damn, that's a heavy hand. I rarely use more than 500mcg of fentanyl for a regular pump case. One place through which I roasted in residency used sufenta for cardiac cases, and the average there was still 50-150mcg per case (usually split a 250mcg vial between two cases, with a touch left to return to Pharmacy).

Lol yeah he has a reputation. We've got several cardiac attendings that run a narcotic heavy anesthetic here (though the rest all use fentanyl). I've given as much as 2mg in a case. Regularly exceed 1mg. We have one attending that won't give more than ~300-400mcg. I have appreciated seeing different approaches.

 

[epidural man]

Sufenta is great for infusions. Look at the context-sensitive half lives of long infusion, and you will see its place.

They are great wake ups. I really like using it - but now just mostly use alfentanil mixed in my propofol.

 

[urge]

Wears off quicker than fentanyl. That’s pretty much it. That’s why cardiac people like it. It allows them to do a deep narcotic anesthetic without the pt staying tubed overnight.

It was introduced as better than fentanyl for many reasons people still quote, but the reality was that it was under patent and big pharma was behind it.

 

[deleted697535]

Lol yeah he has a reputation. We've got several cardiac attendings that run a narcotic heavy anesthetic here (though the rest all use fentanyl). I've given as much as 2mg in a case. Regularly exceed 1mg. We have one attending that won't give more than ~300-400mcg. I have appreciated seeing different approaches.

2mg of suf or fentanyl?

 

[abolt18]

2mg of suf or fentanyl?

Haha sorry, 2mg fentanyl!

 

[dhb]

No reason to use one or the other really.

 

[Wolverines83]

Sufentas CSHT as stated above is roughly equivalent to prop. What I’ve found when running sufenta is there is a nice tail effect after an infusion and patients wake up feeling pretty dang comfortable. They just look very very comfortable (almost like they’re high on opioids....imagine that!) Important to time it right, though!

Fentanyl's csht makes it a crappy infusion drug and remi provides no post op analgesia.

That being said, remi with a bolus of hydromorphone prior to emergence is effective as well. Just doesn’t look quite so slick.

I know that’s a lot of subjective info / opinion but hey, u asked.

 

[dhb]

Sufentas CSHT as stated above is roughly equivalent to prop. What I’ve found when running sufenta is there is a nice tail effect after an infusion and patients wake up feeling pretty dang comfortable. They just look very very comfortable (almost like they’re high on opioids....imagine that!) Important to time it right, though!

Fentanyl's csht makes it a crappy infusion drug and remi provides no post op analgesia.

That being said, remi with a bolus of hydromorphone prior to emergence is effective as well. Just doesn’t look quite so slick.

I know that’s a lot of subjective info / opinion but hey, u asked.

In my experience the great "tail" you mention (as others always do) lasts 20min. If i had to have opioids i'd rather have a tail of methadone.
Anyhow, opioids are probably the most overused and overrated drug in anesthesia. Nowadays i do a great majority of my cases without and i don't miss them at all.

 

[MoMoGesiologist]

In my experience the great "tail" you mention (as others always do) lasts 20min. If i had to have opioids i'd rather have a tail of methadone.
Anyhow, opioids are probably the most overused and overrated drug in anesthesia. Nowadays i do a great majority of my cases without and i don't miss them at all.

What are you giving for induction to prevent response to DL, for maintenance, and for postop?

 

[dhb]

I don't care about response to DL which is mild and transient, i do a block anytime i can, i give a little K if no block and for post op paracetamol with an NSAID or tramadol.

 

[Mman]

I don't care about response to DL which is mild and transient, i do a block anytime i can, i give a little K if no block and for post op paracetamol with an NSAID or tramadol.

that plan kinda depends on the cases and patients you are doing

 

[vector2]

Lol yeah he has a reputation. We've got several cardiac attendings that run a narcotic heavy anesthetic here (though the rest all use fentanyl). I've given as much as 2mg in a case. Regularly exceed 1mg. We have one attending that won't give more than ~300-400mcg. I have appreciated seeing different approaches.

It’s good to learn about all techniques but I think opioid heavy cardiac induction is archaic. For a CABG for instance, Prefer 2mg versed, 150-200mcg fent, norepinephrine pretreat, then prop in 40mg aliquots while watching bp until pt closes eyes, breathe down with a whiff of iso until roc kicks in.

 

[psychbender]

It’s good to learn about all techniques but I think opioid heavy cardiac induction is archaic. For a CABG for instance, Prefer 2mg versed, 150-200mcg fent, norepinephrine pretreat, then prop in 40mg aliquots while watching bp until pt closes eyes, breathe down with a whiff of iso until roc kicks in.

This is a good technique for trainees to try out, particularly the titrating induction meds part, while giving a little pressor to offset the expected slight drop in BP. My induction is mostly the same, but I usually add up to a 0.5mg/kg ketamine (we placed our lines preinduction as a routine, so I usually already had one or two of versed and ten or twenty of ketamine onboard), and reduce my fentanyl and propofol aliquots a little.

 

[vector2]

This is a good technique for trainees to try out, particularly the titrating induction meds part, while giving a little pressor to offset the expected slight drop in BP. My induction is mostly the same, but I usually add up to a 0.5mg/kg ketamine (we placed our lines preinduction as a routine, so I usually already had one or two of versed and ten or twenty of ketamine onboard), and reduce my fentanyl and propofol aliquots a little.

We also place lines awake most of the time and a couple weeks ago was the first time I had considered ketamine. Usually I give what I think ends up being too much versed and fent because I'm essentially running moderate to deep sedation so I can teach trainees. Also, I run precedex throughout the case and I had thought I could start solely the precedex for line sedation but it wasnt potent enough and pt still wasnt comfortable enough for the drape over face / cordis popping through fascia. When I used a mixture of fent, versed, and 30mg of ketamine the pt was absolutely golden, still as a stone during a-line and cordis. And as you said, it reduced the prop requirement during induction.

 

[lakersbaby]

Do you think sufentanil has less risk of hyperalgesia than remi? According to this yes: Effects of different doses of sufentanil and remifentanil combined with propofol in target-controlled infusion on stress reaction in elderly patients which argues the point that remifentanil is a poor drug of choice for any long spine case. Everyone at my institution seems to keep using it for long spine cases (esp CRNAs) but i believe the OIH is real. Sufentanil or precedex infusions are far superior for long spine TIVA cases.