Lap Chole and Narcotics

MaleAPRN · Jul 24, 2005

Just wondering how much narcotic, specifically fent. you give for a typical Lap Chole. I have experienced 3 cases this week were I had to give a very small dose of naloxone to get the patient back breathing. (ET Sevo 0.1, fully reversed, ETCO2 45- 50 and still not breathing.) I typically have the agent off at the time the trocars are removed from the abdomen.

For a lap chole, I typically give 5ccs of fentanyl. Some people give it all upfront. But, I usually start off with 2 ccs on induction...then, titrate the rest. How much do you give? Sounds like you give your patients way too much, since you tell us that you had to reverse them with narcan. Just live with the motto, "Start low, Go slow".

jwk · Jul 24, 2005

For a lap chole, I typically give 5ccs of fentanyl. Some people give it all upfront. But, I usually start off with 2 ccs on induction...then, titrate the rest. How much do you give? Sounds like you give your patients way too much, since you tell us that you had to reverse them with narcan. Just live with the motto, "Start low, Go slow".

Ditto. Once during the week is one thing. Twice would make me rethink my narcotic use, and a third time in a week definitely sounds like a technique problem. Plus, I think you rushed the Narcan anyway. If your SaO2 was fine, I'd let them come up to 55-60 at least before I even thought about the Narcan.

bwt02 · Jul 24, 2005

Ditto. Once during the week is one thing. Twice would make me rethink my narcotic use, and a third time in a week definitely sounds like a technique problem. Plus, I think you rushed the Narcan anyway. If your SaO2 was fine, I'd let them come up to 55-60 at least before I even thought about the Narcan.

I have only been giving about 4cc, 2 upfront and 2 during. Toradol at the end. The CRNA I work with is also perplexed. I swithched to 2cc upfront and then 5mg of Morphine during and have not had the same problem.

heartICU · Jul 24, 2005

I have only been giving about 4cc, 2 upfront and 2 during. Toradol at the end. The CRNA I work with is also perplexed. I swithched to 2cc upfront and then 5mg of Morphine during and have not had the same problem.

It may be the timing of the drug - are you giving the last dose too close to the end?

maturner · Jul 24, 2005

I agree with jwk, why the rush to narcan? What was the rationale for not letting their CO2 build up a little more?

Pete495 · Jan 15, 2006

seems to me since the patient wasnt breathing at all, narcan was indicated. Either that or you're going to be sitting there awhile.

gaspassah · Jan 15, 2006

i think there are several factors to remember.

1 age of patient. elderly usually require less narc. and agent

2 surgeon. are you in an OR where private docs are? lap chole usually 40 min from inc. or teaching facility where lap chole can take 3 hours?

3 what gas are you using, dez shifts the co2 response curve to the right ie pt wont breath as easily unless co2 is almost 60. i see your using sevo, sevo shouldnt be as bad. but may need to 50-60 anyway.

4 some people may disagree with me here but for a healthy patient a small amount of hypoxia, sao2 92% etc is a huge stimulus to breath.

i find apnic oxygenation will increase co2 pretty fast and increase breathing stimulus. put pt on 100% with popoff valve to about 10cm H2O and dont breath them, (this doesnt work as well with obese pts.) in about 2-3 minutes co2 will increase significantly.

me personally, with a fairly healthy pt, 5 cc narc (fent) up front 2-3 on induction then the rest before trocars.

if its a real long case ie resident involvement or small surgical complications i wont add morphine unless pt is spont breathing after deflation of abd. however you will find some surgeons cant close the trocar holes if the pts has muscle tone :uhoh3:

the key to narc use is to remember dose response curve. if you front load plasma levels are smaller at the end therefore there is less resp depression. if you dose intermittantly you may end up with a high plasma level when you need the patient to breath.

just a few thoughts.

d

rn4cicu · Jan 15, 2006

This is the kind of clinical discussion all can benefit from; it is conversations like these that keep me coming back to this site. As a junior student these are the conversation I enjoy the most. I agree with letting the ETCO2 become a little higher before thinking Narcan.

athomas91 · Jan 15, 2006

i agree w/ jwk - if you are giving narcs - your co2 will need to be a little higher to stimulate the breathing in a patient...how long are your lap chole's taking - if they are 30 min or so - 4cc may be too much - and when you add in the pain deleting effects of toradol - they may not need that much

our lap choles are generally fast - i give 2 up front (unless otherwise indicated ie: large patient, concurrent home opioid use etc...) and after they take trocars out - get them breathing and titrate in the rest dependent on their RR... again - differing surgeons and patients will vary -

good luck...

SedareDolorem · Jan 15, 2006

Hmm..

You folks use different units than I´m used to, but..

Generally, for a lap cholecystectomy on a reasonably young patient, I would give 0.1-0.15 mg of fentanyl just before induction. Sevoflurane in oxygen/air mix maintained at approx MAC 1.2. (No real contraindication for nitrous oxide, but I tend do not use it during lap procedures - just a feeling)

Ventilation is adjusted to normoventilation or slight hyperventilation according to ETCO2.

Additional dose of 0.05-0.1 of fentanyl "when surgeon enters the OR" before first incision.

After this, no more narcotics if its at all possible. I rather increase the sevoflurane instead. When the cysticus is out, I reduce ventilation to start accumulate CO2 (same tidal volume as before, but frequency reduced to 3-4 breaths per minute, 80% oxygen). Spontaneous ventilation during closure of troakar incisions. Maybe some ketobemidone (3-5 mg) iv before extubation.

I never use naloxone :wink2:

/Anders, Nurse Anesthesist Sweden

rn29306 · Jan 15, 2006

I have experienced 3 cases this week were I had to give a very small dose of naloxone to get the patient back breathing.

How did these guys look in PACU after narcan? Three out of four times that I have ever had to give it, these pts required labetalol in the post-op period, despite using very small incremental dosing of narcan.