High narcotic technique

LPN & EMT-CT · Oct 7, 2002

What is this high narcotic technique??

I've never heard of it, is it something that the surgeons are doing now that they weren't or what exactly? :confused:

smiling_ru · Oct 7, 2002

No, it is an anesthetic techinique

Half MAC of volatile agent, with front loaded narcotic (fentanyl or sufentanil), titrated to sympathetic response. Re-dose as needed.

kmchugh · Oct 8, 2002

Another way to do high narcotic technique is to use half MAC, with a remifentanil drip. No, I'm not a drug rep, but I really like what remi does for the patient. As Tenesma pointed out elsewhere, there are a lot of different ways to do anesthesia, and if it works safely, it probably ain't wrong. But remember, if you use a remi gtt, you have to be prepared to give a longer acting narcotic in an appropriate dose (i.e. keep the patient breathing) prior to waking the patient.

Tenesma, if you are reading this, we have an MDA here who uses remi for hearts. He gives a loading dose (5 - 7 cc of sufentanil) then starts the remi gtt at about 0.2 mcg/kg/min. I've tried it a couple of times, and really like it. Any thoughts?

Kevin McHugh

smiling_ru · Oct 9, 2002

I like to use remi with obese patients in procedures lasting over an hour. Induction with fentanyl +standard. Half Mac, titrate remi to sympathetic response, at the end titrate morphine to respiratory rate. They wake up right on cue, relaxed and cooperative. No accumulation to worry about/wait for.

Tenesma · Oct 9, 2002

for KMCHUGH:

that is the one thing i love about anesthesia - that made me choose it over all other medical specialties: I can try ten million different anesthetic techniques for the exact same surgical procedure. No other medical profession can do that! (well at least not without getting sued!) And it really sometimes takes the boredom out of a case - i just spent the last 2 days doing all my intubations with a "bougie" without visualization of the cords, for example! I LOVE ANESTHESIA - of course, the surgeons were kinda bug-eyed.

As far as remi goes - I love it... PERIOD. It rocks, feel the same way about the other short-acting (sufent, alfent). As far as hearts go - they tend to be more routine, so if you can spice it up with remi go for it (it just adds another drip to worry about though).

And I agree with Smiling_RU, being able to take a patient through a procedure with a relatively brisk but painless wake-up is definitely an ego booster... so this would be a good example for how despite the high cost of remi, the shortened PACU stay may be worth it (financially)?? who knows...

on a side note, I am soo glad that this forum has finally turned away from the md vs crna topic towards more interesting discussions...

tenesmus

kmchugh · Oct 13, 2002

Since we are talking about remi, thought I'd relate an experience I had this week.

Doing a big back case on a 14 year old with scoliosis, needed to be awakened in the middle of the case. I'd never done a mid case wake up before, and was concerned about it. Figured remi was the best option. At the appropriate time, turned the remi (run at .2-.4 mcg/kg/min) and the agent (run forane at about .6-.8 inhaled concentration). The short story is that the wake up was very smooth. The patient lifted her head, I told her to put it back down and wiggle toes on both feet. She did, and I gave her 150 mg pentothal and turned the remi and agent back on, and she was back asleep within about 10 - 15 seconds. Also gave 2 mg versed after the pentothal, for retrograde amnesia. (The MDA I worked with didn't thing versed caused retrograde amnesia, but it seems to have worked. At the end of the case, the surgeon complimented me for the smoothest wake up he had ever had. I blame the remi.

Kevin McHugh

MICU RN · Oct 13, 2002

KEvin:

Could you reexplain what remi is again and state its full name? Thanks.

Tenesma · Oct 13, 2002

the interesting thing about versed is that we know that it causes some antegrade amnesia.... the issue with retrograde amnesia is less clear - some say yes, some say no. More than likely in this case it was the volatile anesthetic providing some amnestic coverage (a certain percentage is still lingering in the patients brain)... I myself love isofluorane as a volatile - if appropriately timed it gives very, very smooth emergences without the combativeness and the choking, etc. out of experience if you had run sevo or des it might have been a lot less smooth. i think you chose the perfect combination of volatile and narcotic!

btw, i would have given some versed too...

tenesma

kmchugh · Oct 13, 2002

Anthony

Remi is remifentanil, a very potent, very short acting narcotic. The reason it is so short acting is that, unlike other narcotics, remi is quickly metabolized by tissue and blood esterases. It's potency is demonstrated by the fact that it is generally given in drip form, with the usual anesthetic maintenance dose being in the 0.2-0.5 range. Though I have seen references that list 2 mcg/kg/min as an acceptable dose, I have never had to go that high to achieve a nice anesthetic level. Bolus doses are possible, though, again, I have never had to give one. The great thing about remi is that it is so rapidly metabolized, the patient will wake up far more rapidly than if using a volitile agent alone. You have to remember, however, that remi wears off quick, so you have to give some kind of narcotic with longer action prior to turning off the remi, otherwise the patient could easily wake up with no pain relief on board. Once you are behind that 8 ball, its hard to get out.

It is also a great anesthetic for morbidly obese patients, since it wears off more rapidly than most volitile agents. Volitile agents are lipid soluble, so they get stored in the fatty tissue. Agent stored in this fashion is slowly released, and I think I saw a study that demonstrated measureable levels of forane exhaled by obese patients as long as 12 -24 hours after a longer duration surgery.

Kevin McHugh

meandragonbrett · Oct 13, 2002

Is there any relation of remi to fentanyl ? J\w

Brett

smiling_ru · Oct 13, 2002

Kevin,

I use remi for wake-up procedures in a similar manner, the only difference would be a switch from iso to nitrous about 10 minutes from wake up. Turn them both off when they are ready, takes only a minute or so for appropriate respones.

My original question stemmed from an interest in what other people are doing with regard to general surgeries and high narcotic technique. A lot of people seem to do it, although there is very little in the the literature regarding technique, other than in cardiac surgery.

I like to front load sufentanil (shorter context sensitive half life, smoother wake up, MUCH better sympatholysis then fentanil) Usually dose between .25 and 1/mcg/kg. Generally need to redose an hour to an hour and half in, then I just titrate to sympathetic response.

But, this technique has just come from trial and error, and I wonder if there might be a better way to do it. While also being interested in the various ways that other people do it. Thanks!!