Fentanyl in GA and RA_edit

7/28/2019 Fentanyl in GA and RA_edit

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The Role of Fentanylin GA and RA.


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Since than (1846) Evolution of Anesthesia

from Ether to Fentanyl


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HypnoticAnalgesiaRelaxation

1846 19261990 2000

BalancedAnesthesia 1926

(Lundy)

Unconsciousness hypnoticAntinociceptive analgesia

Relaxation muscle relaxant

HalothaneN2O

Pavulon/ curare

BalancedAnalgesia

EraODC

80 years 75 years

PremedicationSA/ ScopolamineMo. or Pethidine

PremedicationSA

Mo. or Pethidine

Im worried that Iwont wake up

Main Goal of Anesthesia isto Bring Back Patients

Alive

No premedicationNo SA

No opiates

Not onlyAwake up and Analgesia,

but alsofull alert and can walk

home

Im worried tohave PAIN,

After surgery

Save Anesthesia

EtherOnly

EraModern Anesthesia


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ETHER

Except Ether(1848) as a very old andtypical anesthetic agent which mayproduce, AMNESIA( HYPNOTIC)ANALGESIA & RELAXATIONno otheranesthetic agent may produce triadanesthesia. But it has many disadvantages.


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The feat earned Morton theepitaph in Massachusetts

The Inventor of anesthetic inhalationBy whom pain in surgery was annulled

Since whom science has control of PAINBefore whom, surgery as agony


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John Lundy (1926) from Mayo Clinic firstintroduced BALANCED ANESTHESIA

Antinociceptive analgesicUnconsciousness hypnotic

Relaxation muscle relaxant

BALANCED ANESTHESIA


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In 75-90 our typical anesthesiaNitrous OxideFlouthane

Pancuronium Br /CurareStill has some disadvantages

BALANCED ANESTHESIA


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Since than, scientis looking forIdeal:

1. Analgesic2. Hypnotic3. Muscle relaxant

BALANCED ANESTHESIA


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Strong ANALGESIC FENTANYL

Good HYPNOTIC PROPOFOL

RELAXATION N D M R


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Fentanyl

Discovered in 1963 by Dr. PaulJanssen

Synthethic opioidStrong Opioid 100x to MorphinePure agonistFentanyl is the reference analgesic inanaesthesiaNo ceiling effect

12


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Mu1 : analgesia (supraspinal, spinal), euforia,

miosis, bradikardi, hipotermi,retensi urine.

Mu2 : analgesia (spinal), depresi ventilasi,

konstipasi (bermakna).

Kappa : analgesia (supraspinal, spinal), disforia,sedasi, miosis, diuresis.

Delta : analgesia (supraspinal, spinal), depresiventilasi, konstipasi (minimal),retensi urine.


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Modulation


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Opioid mechanisms

Substance Petc

Spinal cord neurone

C-fibre

Descendingcontrols

To the brain

Glutamate


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Opioid mechanisms

Substance Petc

Spinal cord neurone

C-fibre

Descendingcontrols

To the brain

Opioid

Glutamate


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Fentanyl

IndicationsFentanyl is used in the treatment of acute

pain and to depress breathing in patientsbeing ventilated . It may also be given as aninfusion under the skin in palliative care

patients who have intolerable side effectsfrom Morphine.


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Fentanyl Dosing For Our

Protocols50-100mcg IV or 1-2 mcg/kgMay repeat dose every 5 minutes until max of

3mcg/kg. Pay special attention to your dosing this is theonly medication we have that is given in Micro-

grams (mcg).


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Fentanyl vs MorphineANALGESIC MEDICATION OPTIONS(Choose one) Fentanyl 50-100 mcg IV (1-2 mcg/kg)

may repeat dose every 5 minutes until maximumof 3 mcg/kg OR

Morphine sulfate 2-5 mg IV

(0.05 mg/kg)may repeat dose every 5 minutes until maximum of 0.2 mg/kg


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Fantanyl Dosing (Continued)

Fentanyl supplied in ampules of 100mcg/2mlor 250mcg/5ml


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Fentanyl Dosing ( Continued)

So what's the concentrationfor 100mcg/2ml???50mcg/ml Right!For 250mcg/5ml???

50mcg/ml You got it!


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Fentanyl

PharmacokineticsIntramuscularOnset 7-15 minutes

Peak 15 minutesDuration 1-2 hours

IntravenousOnset few minutesPeak few minutesDuration 30-60 minutes


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Fentanyl PrecautionsOver SedationRespiratory Depression RR 12 with

sedationPin point pupil

Respiratory depression from opioids is manifested by:a reduced drive to breathreduced rate,often associated with sighing pattern.


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Fentanyl

Precautions/Warnings Cont.Alcohol and Drugs of Abuse - May be expected tohave additive CNS depressant effects when used

in conjunction with alcoholCardiac Disease may produce bradycardiashould be used with caution in patients withknown bradyarrhytmias.Hepatic or Renal Disease Caution because of the hepatic metabolism and renal excretion of Fentanyl.


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Fentanyl Contraindications

Intermittent painRespiratory depression

Acute or severe asthmaParalytic ileus - paralysis of the intestineKnown hypersensitivity

Opioid induce Hyperalgesia


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Fentanyl Side Effects Common &Uncommon

CommonRash, Nausea, Vomiting , Drowsiness, DryMouth, Dizziness, Difficulty Urinating,Constipation (prolonged use), Constricted pupils

UncommonRigid chest wall, Decreased Breathing,

Confusion, Itching, Slowing or Elevated HR,ABD pain.


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Considerations

Parenteral dose may be given diluted orundilutedAdminister IV over 1 to 2 minutesProtect from lightClosely monitor vital signsRespiratory depression may out last the

analgesic effectEffects may be reversed by naloxon(Narcan)


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Fentanyl-Conclusion

Very good analgesic ( potent analgesic)Safe to administer at lower, slow infusion rates.Low histamine effects.

Short duration.Avoid CNS injury, respiratory, renal, and hepaticfailure.

Reserve for pain management outside the cardiacsetting.


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Fentanyl In Summary

Fentanyl is a potent analgesicDose is 1-2 mcg/kgReversal agent is Naloxon (Narcan)


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Barier in using opioid as a

strong analgesicwhen mention about pain it side effect iscoming up not the benefits Sedation

Nausea /VomitingConstipation

Pruritus

Respiratory -

depressionAddictionTolerance


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Role of Fentanyl inAnesthesia : 1. Premedication

Premedication 50 to 100 mcg iv or im

2. General AnesthesiaLow (2mcg/kg), Moderate(2-20) or High dose (20-50)

3. Adjunct to General Anesthesia with inhalation4. Adjunct to Regional Anesthesia

50 to 100 mcg , when additional analgesia is required.5. Postoperatively (recovery room)

50 to 100 mcg may be administered iv or im to control of pain.The best via epidurally + LA


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Propofol

Before introduction of protofal, thiopental(ultra short acting barbitural) is commonlyused.Good for induction expect for its painfulduring the injection, can be overcome by Ledocain 1 mg/Kg BW Fentanyl 1 ug/Kg BW


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Propofal is insoluble in water, therefore,propofal is formulated as emulsion containing

10% soybean oil 2.25% glyserine 1.2% lecetin

Major componen egg yolk fractionGood for supporting bacterial growth, sosterilitation is very important.

Propofol


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Propofal primary act as hypnotic, has noanalgesia.Decreas CBF and CMRO2 ICPThis effect equal with thiopentalIt has antiemetic effect

Rapid onset 30 optimal 2 duration about 10

Propofol


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Modern Anesthesia

Premedication (SA, Mo, Pethidine, Diazepam) Midazolam Barbiturate (Thiopental) Nitrous Oxide, (only oxygen and air) Depolarizing Muscle Relaxant (SCC) Long Acting NDMR (Pancuronium Bromida) Inhalation Anesthetic, less and less.

Propofol as strong hypnotic Fentanyl, Sufentanil, Alfentanil, as strong analgesics Rocuronium, Vecuronium, Atracurium, etc. as NDMR

TIVA + Epidural Analgesia

T I V A

N O

! ! !


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Epidural Anesthesia

Epidural is the main modality inAcute Pain Service.

Epidural can be used as;Epidural Anesthesia

Epidural Analgesia


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Epidural guidelines 2010The following operation shoud be inserted Epidural anesthesia and analgesia

(postop pain management)GI - Gasterectomy

- Hepatectomy

- APR

- Whipples

GU/GY - Nephrectomy

- Radical cystectomy

- RPLND

Thoracic - Oesophagectomy

- Lung resection

- Rib resection

Orthopedics - Total knee replacement

- Total hip replacement

- Hemipelvictomy

- Sacral Cordomas


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Grass JA, Problems in Anesthesia1998,10(1):45-70


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Level of catheter insertion

Level of insetion shoud be in the middle of dermatome of planned incision.

Thoracotomy ; Th 5 -7

Upper abdominal incision ; Th 7 9Lower abdominal laparatomy ; Th 10 11Pelvic sugery/ Lower limb surgery ; L 2-4


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Epidural technique


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H d


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Human sensory dermatomes


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Reduced Dose of - Fentanyl- Propofol- NDMR

- LA

FENTANYL

PROPOFOLN D M R

EPIDURAL

ANALGESIC

RELAXATION

HYPNOTIC

EARLY WAKE UP WITH NO PAIN


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SEKIAN DAN TERIMA

KASIHSEMOGA ADA MANFAATNYA

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Fentanyl in GA and RA_edit

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