1 / 59

Rational Use of Opioids: Intraoperative Postoperative

Actual Orders Written at Stanford: June 16, 2005. Case 1. 40 y.o. 81 kg ASA PS2 maleAnterior cervical discectomy3 hour anesthetic with sevoflurane, N2OIntraoperative:Midazolam 4 mgFentanyl 500 mgHydromorphone (Dilaudid) 1 mgPost op orders:Morphine 2-4 mg q 5 min to 30 mgFentanyl 25-50 mg q 5 min to 500mgMeperidine 5-10 mg q 5 min to 50mgNaloxone 0.1 mg for RR<6 .

Ava
Download Presentation

Rational Use of Opioids: Intraoperative Postoperative

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Rational Use of Opioids: Intraoperative & Postoperative Larry Saidman Steve Shafer

    2. Actual Orders Written at Stanford: June 16, 2005

    3. Case 1 40 y.o. 81 kg ASA PS2 male Anterior cervical discectomy 3 hour anesthetic with sevoflurane, N2O Intraoperative: Midazolam 4 mg Fentanyl 500 mg Hydromorphone (Dilaudid) 1 mg Post op orders: Morphine 2-4 mg q 5 min to 30 mg Fentanyl 25-50 mg q 5 min to 500mg Meperidine 5-10 mg q 5 min to 50mg Naloxone 0.1 mg for RR<6

    4. Case 2 52 y.o. 128 kg ASA PS2 male Scalp advancement 4 hour anesthetic with isoflurane, N2O Intraoperative: Midazolam 2mg Fentanyl 600 mg Post op orders: Morphine 2-4 mg q 5 min to 10mg in first 90 minutes patient was drowsy and received nothing

    5. Case 3 81 y.o. 80 kg ASA PS2 male Lumbar decompression 3 hour anesthetic with N20 and propofol infusion at 75-100 mg/kg/min Intraoperative: fentanyl 250 mg Post op orders: Morphine 1mg q 5 min to 12 mg Fentanyl 25-50 mg q 5 min to 150 mg Meperidine 12.5 mg q 5 min to 25mg for shivering

    6. Summary of Three Cases Case 1: 40 YO 81 kg MS 0.375 mg/kg, fent 7.5 mcg/kg Case 2: 52 YO 128 kg MS 0.08 mg/kg Case 3: 81 YO 80 kg MS: 0.15 mg/kg, fent 2 mcg/kg

    7. “Don’t tell me what to do!” Recognizing the variety of practices among the large number of anesthesiologists at Stanford and not implying that there is/are best practice(s) among the anesthesiologists at Stanford I ask Dr Shafer to address the following questions:

    8. Questions: Given the variations in age, weight, and surgical procedures, does the variation in postoperative opioid prescriptions make clinical or PK/PD sense? Does the PK/PD of morphine make it the best (or even a good) opioid for treatment of acute post-op pain? Based on known PK/PD of opioids, what opioid (including remifentanil) might be better used intra-operatively for breakthrough autonomic stimulation as well as in anticipation of postoperative pain?

    9. Disclosure I’ve consulted with Janssen (transdermal fentanyl), Cygnus (transdermal fentanyl), Anaquest (transdermal fentanyl), Alza (transdermal fentanyl), Anesta (oral transmucosal fentanyl), Glaxo (remifentanil), Abbott (remifentanil), Delex (inhaled liposomal fentanyl), and Durect (chronic sufentanil) FDA Anesthesia Advisory Panel for Oxycontin (oxycodone) and Pallidone (hydromorphone)

    10. “Don’t tell me what to do!” OK, I won’t tell you what to do, but you are lousy at treating post operative pain. You are in good company. We all do poorly here. 70-80% of patients have moderate to severe postoperative pain Svensson et al. Assessment of pain experiences after elective surgery. J Pain Symptom Manage 2000; 20: 193-201. Fundamental problem, we don’t have an adequately safe and efficacious analgesic The dose of opioid in every patient is limited by toxicity.

    11. “Don’t tell me what to do!”

    12. Morphine Endogenous ligand Slow rise to peak effect Absolute peak analgesic effect is at 90 minutes after bolus injection! Active metabolite Morphine-6-glucuronide is unlikely to contribute to analgesic effects at standard OR doses. Will contribute to effects with chronic dosing Especially in renal failure Not as full efficacy as fentanyl series of opioids

    13. Morphine Pharmacokinetics

    14. Morphine Pharmacokinetics

    15. Morphine Onset

    16. Simulation of Morphine Time Course

    17. Fentanyl Pharmacologically “clean” 100% efficacious (in contrast to morphine) The first of the “fentanyl” series (obviously…) Available in transdermal, submucosal, sublingual, and (soon) inhaled forms. Free!

    18. Morphine vs. Fentanyl PK

    19. Morphine vs. Fentanyl PK

    20. Morphine vs. Fentanyl Onset

    21. Hydromorphone A rapid onset morphine No histamine release About 8 fold more potent than morphine No active metabolite Good choice for PCA, post-op analgesia

    22. Comparative Hydromorphone PK

    23. Comparative Hydromorphone PK

    24. Comparative Onset of Hydromorphone

    25. Sufentanil 10 fold more potent than fentanyl Slightly slower onset More rapid recovery Very clean pharmacologically

    26. Comparative Onset of Sufentanil

    27. Meperidine Bad Drug! No role in the management of pain Toxic metabolite Normeperidine ? seizures Renally excreted Negative inotrope Causes tachycardia (anticholinergic) Complex interactions MAO syndrome when combined with MAO inhibitors Useful for shivering, perhaps as a local anesthetic

    28. Comparative Onset of Meperidine

    29. Alfentanil Less potent than fentanyl Much more rapid onset (including more rapid onset of rigidity and respiratory depression) Much more evenascent effect with a single bolus With brief infusions will be almost indistinguishable from fentanyl, except for potency

    30. Remifentanil Similar potency to fentanyl Pharmacokinetics are in a class by themselves (ester metabolism) Reduce the dose by about 2/3s in the elderly No pharmacokinetic interactions Onset is similar to alfentanil

    31. Comparative Onset of Alfentanil and Remifentanil

    32. Methadone Longest terminal half-life (about 1 day) May accumulate during titration to steady state Supplied as a racemic mixture L methadone is an opioid agonist D methadone is an NMDA antagonist Underutilized in anesthesia practice

    33. Comparative Onset of Methadone

    34. Fundamental PK/PD Parameters

    35. Comparative Opioid PK

    36. Context Sensitive Half Time

    37. 50% Effect Site Decrement Time

    38. Equivalent doses at 10 min to 50 ?g fentanyl

    39. Intraoperative potency: 100 ?g/hour fentanyl at 2 hours

    40. Case 1 40 y.o. 81 kg ASA PS2 male Anterior cervical discectomy 3 hour anesthetic with sevoflurane, N2O Intraoperative: Midazolam 4 mg Fentanyl 500 mg Hydromorphone (Dilaudid) 1 mg Post op orders: Morphine 2-4 mg q 5 min to 30 mg Fentanyl 25-50 mg q 5 min to 500mg Meperidine 5-10 mg q 5 min to 50mg Naloxone 0.1 mg for RR<6

    41. Case 1

    42. Case 1

    43. Case 1

    44. Case 1 40 y.o. 81 kg ASA PS2 male Anterior cervical discectomy 3 hour anesthetic with sevoflurane, N2O Intraoperative: Midazolam 4 mg Fentanyl 500 mg Hydromorphone (Dilaudid) 1 mg Post op orders: ? Do whatever the hell you want ? Give naloxone if you screw up

    45. Case 2 52 y.o. 128 kg ASA PS2 male Scalp advancement 4 hour anesthetic with isoflurane, N2O Intraoperative: Midazolam 2mg Fentanyl 600 mg Post op orders: Morphine 2-4 mg q 5 min to 10mg in first 90 minutes patient was drowsy and received nothing

    46. Case 2

    47. Case 3 81 y.o. 80 kg ASA PS2 male Lumbar decompression 3 hour anesthetic with N20 and propofol infusion at 75-100 mg/kg/min Intraoperative: fentanyl 250 mg Post op orders: Morphine 1mg q 5 min to 12 mg Fentanyl 25-50 mg q 5 min to 150 mg Meperidine 12.5 mg q 5 min to 25 mg for shivering

    48. Case 3

    49. Case 3

    50. Interindividual Variability 1

    51. Interindividual Variability 2

    52. Interindividual Variability 3

    53. Recommendation 1 Just use fentanyl for post-op analgesia 25 mg q 5 min Max of 250 in young patients, 150 in elderly 3-5 minute peak onset provides rapid relief, but no so rapid that the patient stops breathing Rapid peak makes it easy to titrate Nurses are familiar with it Logical choice for PCA Free If you can’t get the patient comfortable with fentanyl, you won’t succeed with another opioid possible exception of methadone

    54. Recommendation 2 Hydromorphone 1 mg q 5-10 min Max of 10 mg in young patients, 6 mg in elderly 5-10 minute peak onset provides rapid relief, but no so rapid that the patient stops breathing Still easy to titrate Nurses are familiar with it Also a logical choice for PCA Inexpensive

    55. Recommendation 2

    56. Opioids can’t do it all Differences in ventilatory control with sleep PACU nurses understand this better than anesthesiologists Local anesthetics should be first line of analgesic therapy Many drugs show analgesic synergy with opioids Clonidine, dexmedetomidine (a2 agonists) Ketamine / magnesium (NMDA antagonists) NSAIDs (COX antagonists) Nicotine?

    57. Recommendation 3 If severe post-op pain is expected: Methadone 5-15 mg 1 hour before the end of the case Ketamine 10-20 mg 30-60 min before the end of the case Magnesium 1 gm 30-60 min before the end of the case Ketorolac 30 mg 30 min before the end of the case Post-Op: Fentanyl 25 mg q 5 min to max 250 or Hydromorphone 1 mg q 5 to max 10

    58. Recommendation 4 Listen to your PACU nurses: Infinitely more experience than you have titrating opioids to pain Recognize changes in ventilatory drive between awake and asleep states Know to start with bigger dose, more frequent dosing, and then move to smaller doses, less frequent dosing Know when pain is out of proportion to surgery

More Related