High narcotic technique help

athomas91 · Mar 27, 2004

i haven't yet done that technique...but one of my instructors is a big fan...

he uses a Remi drip - medicates w/ a longer lasting med in the middle/end of the case for post-op pain. but i am sure that others on this board will be of more assistance...good luck

smiling_ru · Mar 27, 2004

There are not a lot of references out there unless it is in the discussion of CV cases. I use this technique almost exclusively. The patients wake up faster, and IMHO smoother. The hospital where I currently work does not have sufenta so I use fentanyl. In school we used Sufenta as well, which I preferred as it does not accumulate.

I do not use it in cases that will be less than an 45 minutes or so. (As we don't have remifentanil either which is great for shorter cases) I tend to use Isoflurane rather than des or sevo with it.

My steps

1. Standard induction

2. Isoflurane set to an end tidal of between 0.5 and .07% (.5 in elderly/fragile, .7 in young)

3. If using fentanyl I try to get at a minimun 500mcg on board before incision. ( Or between 5 and 10 mcg/kg depending on the patient).

If using Sufenta I would try to get between .5 and 2 mcg/kg prior to incision or 100mcg. (tend to give 100mcg unless the patient was out of the "normal" range in weight or health.

4. Those dosages generally do not require re-dosage for an hour (although some require more quickly). Re-dose in response to changes associated with increased sympathetic response from the patient. When re-dosing I determine the amount to give based on the length of time left in the surgery (will not give more than 2 cc if less than a half hour). If I have lots of time will tend to re-dose around 250mcg at a time (again depending on the patient). If using Sufenta I would re-dose around 20mcg at a time.

5. When the sugeon is no subq or skin depending on the incision I will get the patient breathing back (I will usually save 50 mg propofol from induction and put in the IV line (Don't give it unless I need to) at this point just in case they become too light. This has happened a few times, just as they start to breath back, they will move a bit.

6. Turn the gas off when the surgeon is finished, unless there are slings or extensive dressings to be put on, then I wait for that. The patient is usually ready to extubate within 2-5 minutes.

7. Must have some paralytic on board for high narcotic techniques. I will let it wear off near the end, but I don't reverse it until the surgeon is done.

8. I have never had a patient with awareness, (we do post-op rounds and that is the first question on our list) nor have I had one not wake up quickly. I have only had one patient who required post-op ventilation and this was related to morbid obesity and surgery rather than anesthetic technique.

Try not to bounce your gas up and down in response to changes in blood pressure and heart rate, just use the narcotic, if the case is suitable and you are not getting the sympatholytic response you can add nitrous. !5% of patients are not responsive to the sympatholytic effects of Fentanyl (which is another reason I prefer Sufenta) In those patients you either add nitrous or you have to increase the Isoflurane.

Anyway thats the gist of the way I do it. Hope it helps

WntrMute2 · Mar 27, 2004

Thanks smiling RU. The CRNA I learned a bit from used 70% nitrous and NO volatile agent so his technique was a bit different. But your technique will certainly help me get started.

sweetdreams · Mar 27, 2004

Smiling_RU

Thanks for sharing on this topic. I'm in my third month of clinical and have been impressed by the smoothness of a high narcotic technique. I have two questions

1. Why Iso over Des or Sevo

2. Do you ever use MS after the patient is breathing back at the end of the case for longer post-op pain control? ( what I have seen from a couple of CRNAs is titrating MS to slow rr to 10-12/min)

Dave

TraumaNurse · Mar 27, 2004

I do not start clinicals until June so I am asking this for interest sake. Do you have any problems with hypotension with high dose narcs, especially MS? Is the key in keeping pts euvolemic or do you sometimes have to substitute with a little phenylephrine? Just curious. I love these clinical discussions! Thanks.

smiling_ru · Mar 27, 2004

Dave,

Most of the time the patients do not breath at higher rates etc. If they do I will titrate morphine but it is rare.

The only reason that I use Isoflurane is that I can't seem to get the same effects with the others. I am not sure why, I have tried with half mac sevo, but only in short cases it just does not work as well. With desflurane you tend to have higher heart rates and blood pressures so it is harder to titrate to sympatholytic effect. I am sure there are people out there that do it with those drugs, and that it works fine I just have not mastered it.

smiling_ru · Mar 27, 2004

I do not start clinicals until June so I am asking this for interest sake. Do you have any problems with hypotension with high dose narcs, especially MS? Is the key in keeping pts euvolemic or do you sometimes have to substitute with a little phenylephrine? Just curious. I love these clinical discussions! Thanks.

Narcotics have more stability from a CV standpoint, they do not depress cardiac output and there is a limit to vasodialtion. That being said, there are times when the patient is hypotensive for various reasons, but in my experience I have more problems with hypotension and high gas rather than high narcotic.

Passin' Gas · Mar 27, 2004

Great explanation of the technique. I use a very similar technique and found it works well. And you pointed out a key thing: keeping the gas steady and using opioid to control hemodynamic changes to surgical stimuli. The only other minor point I learned is to get the gas off, usually an end-tidal 0.2% for isoflurane and CO2 up. Depending on how much time I have/speed of surgical closure, I'll turn on nitrous at the end as the isoflurane concentrations are decreasing; the propofol in line is a good practice to keep the patient still if needed.

Thanks for sharing.

PG

kmchugh · Mar 28, 2004

One of my favorite techniques for carotids (which I don't do at my current location) and a lot of other vascular techniques is a combined forane/remifentanil technique. It is particularly useful with carotids, in that I didn't seem to get the wide swings in bp that often accompany that patient population. It was great. To quote Tenesma, remi ROCKS.

Generally, when doing this technique, I started with a bolus dose of 3-5 cc fentanyl, with the goal of getting 5 cc on board prior to incision (gives a longer acting narcotic coverage, smooths emergence). With the bolus, I start the remi at about 0.5 mcg/kg/min, and titrate that more than anything else in the case. Also run forane at about half mac, and (with carotids) neosynepherine gtt titrated to maintain SBP. I have also tried induction without fentanyl, running the remi at 1 mcg/kg/min, then giving other induction meds as the patient fell asleep from the remi. But, when you do that, you have to remember to titrate on a little longer acting narcotic at the end of the case.

When we got to about 15 minutes prior to closure, I turned the remi down to about 0.05 mcg/kg/min, and let the patient wake up with that running. Does a great job of smoothing the emergence. Just prior to moving the patient over to the cart to go to PACU, turn off the remi. With an induction bolus of fentanyl, most of my patients stayed VERY comfy, but were awake and alert for neuro checks. Worked great.

We don't have remi where I currently work, but I am thinking about having the pharmacy order it. We do some bigger belly cases, and I'm just wondering how well it will work for those, especially in the older population.

Kevin McHugh

kmchugh · Mar 28, 2004

All of which made me think of a couple of questions I've been meaning to ask about remi:

There is a recipie out there for a remi/propofol mixture that can be run as a TIVA or near TIVA. Anybody heard of this concotion?

Also, I have heard some rumors that some folks are using remi drips for endoscopy sedation. Anyone else heard of this? Seems to me to be an expensive way to "skin the cat."

Kevin McHugh

Gaspasr · Apr 1, 2004

I've used 5-10 cc of Remi in 50 cc of propofol. I mix my Remi (5mg in 100cc) and then add the 5-10 cc of Remi to the propofol. Titrate to desired effect. Remi rocks for sure, plus I think its better on the patient. My patients that get Remi move themselves over after surgery. I think narcotics are better than gas anyways, less stress on the body than with gas.