The Role of Fentanyl in GA and RA.

Since than (1846)

Evolution of Anesthesia

from Ether to Fentanyl

Ether Only
Hypnotic Analgesia Relaxation

Unconsciousness hypnotic Antinociceptive analgesia Relaxation muscle relaxant

Era Modern Anesthesia

Balanced Anesthesia 1926 (Lundy)

Halothane N2O Pavulon/ curare

Balanced Analgesia

Era ODC

80 years

75 years

1990

2000

1846
Premedication SA/ Scopolamine Mo. or Pethidine

1926
Premedication SA Mo. or Pethidine

Save Anesthesia

No premedication No SA No opiates

Im worried that I wont wake up Im worried to have PAIN, After surgery

Main Goal of Anesthesia is to Bring Back Patients Alive

Not only Awake up and Analgesia, but also full alert and can walk home

ETHER
Except Ether(1848) as a very old and typical anesthetic agent which may produce, AMNESIA( HYPNOTIC) ANALGESIA & RELAXATION no other anesthetic agent may produce triad anesthesia. But it has many disadvantages.

The feat earned Morton the epitaph in Massachusetts

The Inventor of anesthetic inhalation By whom pain in surgery was annulled

Since whom science has control of PAIN Before whom, surgery as agony

Amputation as agony before Ether was invented

BALANCED ANESTHESIA
John Lundy (1926) from Mayo Clinic first introduced BALANCED ANESTHESIA Antinociceptive analgesic Unconsciousness hypnotic Relaxation muscle relaxant

BALANCED ANESTHESIA
In 75-90 our typical anesthesia
Nitrous Oxide Flouthane Pancuronium Br /Curare
Still has some disadvantages

BALANCED ANESTHESIA
Since than, scientis looking for Ideal:

1. Analgesic 2. Hypnotic 3. Muscle relaxant

Strong ANALGESIC

FENTANYL

Good HYPNOTIC

PROPOFOL

RELAXATION

NDMR

Fentanyl
Discovered in 1963 by Dr. Paul

Janssen Synthethic opioid Strong Opioid 100x to Morphine Pure agonist Fentanyl is the reference analgesic in anaesthesia No ceiling effect

12

Presynaptic & Post Synaptic Receptors

Dorsal Horn Neurons

 Mu1

: analgesia (supraspinal, spinal), euforia, miosis, bradikardi, hipotermi, retensi urine. : analgesia (spinal), depresi ventilasi, konstipasi (bermakna). sedasi, miosis, diuresis.

Mu2

Kappa : analgesia (supraspinal, spinal), disforia,

Delta

: analgesia (supraspinal, spinal), depresi ventilasi, konstipasi (minimal), retensi urine.

Modulation

Opioid mechanisms
Descending controls To the brain C-fibre

Glutamate

Substance P etc

Spinal cord neurone

Opioid mechanisms
Descending controls To the brain C-fibre Glutamate

Substance P etc

Opioid

Spinal cord neurone

Fentanyl
Indications
Fentanyl is used in the treatment of acute pain and to depress breathing in patients being ventilated. It may also be given as an infusion under the skin in palliative care patients who have intolerable side effects from Morphine.

Fentanyl Dosing For Our Protocols

50-100mcg IV or 1-2 mcg/kg
May repeat dose every 5 minutes until max of

3mcg/kg. Pay special attention to your dosing this is the only medication we have that is given in Micrograms (mcg).

Fentanyl vs Morphine
ANALGESIC MEDICATION OPTIONS

(Choose one) Fentanyl 50-100 mcg IV (1-2 mcg/kg) may repeat dose every 5 minutes until maximum of 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

Fantanyl Dosing (Continued)

Fentanyl supplied in ampules of 100mcg/2ml

or 250mcg/5ml

Fentanyl Dosing (Continued)

So what's the concentration

for 100mcg/2ml??? 50mcg/ml Right! For 250mcg/5ml??? 50mcg/ml You got it!

Fentanyl Pharmacokinetics
Intramuscular
Onset 7-15 minutes Peak 15 minutes Duration 1-2 hours

Intravenous
Onset few minutes Peak few minutes

Duration 30-60 minutes

Fentanyl Precautions
Over Sedation

Respiratory Depression RR 12 with sedation

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

Fentanyl Precautions/Warnings Cont.

Alcohol and Drugs of Abuse - May be expected to have additive CNS depressant effects when used in conjunction with alcohol
Cardiac Disease may produce bradycardia should be used with caution in patients with known bradyarrhytmias. Hepatic or Renal Disease Caution because of the hepatic metabolism and renal excretion of Fentanyl.

Fentanyl Contraindications
Intermittent pain Respiratory depression Acute or severe asthma Paralytic ileus - paralysis of the intestine Known hypersensitivity Opioid induce Hyperalgesia

Fentanyl Side Effects Common & Uncommon

Common
Rash, Nausea, Vomiting , Drowsiness, Dry Mouth, Dizziness, Difficulty Urinating, Constipation (prolonged use), Constricted pupils

Uncommon
Rigid chest wall, Decreased Breathing, Confusion, Itching, Slowing or Elevated HR, ABD pain.

Considerations
Parenteral dose may be given diluted or undiluted Administer IV over 1 to 2 minutes Protect from light Closely monitor vital signs Respiratory depression may out last the analgesic effect Effects may be reversed by naloxon

(Narcan)

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 hepatic failure.

Reserve for pain management outside the cardiac

setting.

Fentanyl In Summary
Fentanyl is a potent analgesic Dose is 1-2 mcg/kg Reversal agent is Naloxon (Narcan)

Barier in using opioid as a strong analgesic

when mention about pain it side effect is coming up not the Respiratory - benefits Sedation

depression Addiction Tolerance

Nausea /Vomiting Constipation Pruritus

Role of Fentanyl in Anesthesia:

1. Premedication
Premedication 50 to 100 mcg iv or im

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

3. Adjunct to General Anesthesia with inhalation

4. 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

Moderen Anesthesia
Combination of these 3

regiments (propofol, fentanyl and vecuronium ) as Balanced Anesthesia is considered as modern anesthesia.

Propofol
Before introduction of protofal, thiopental

(ultra short acting barbitural) is commonly used. Good for induction expect for its painful during the injection, can be overcome by Ledocain 1 mg/Kg BW Fentanyl 1 ug/Kg BW

Propofol
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 fraction Good for supporting bacterial growth, so sterilitation is very important.

Propofol
Propofal primary act as hypnotic, has no

analgesia. Decreas CBF and CMRO2 ICP This effect equal with thiopental It has antiemetic effect Rapid onset 30 optimal 2 duration about 10

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.

NO ! ! !
TIVA

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

TIVA + Epidural Analgesia

Epidural Anesthesia
Epidural is the main modality in

Acute Pain Service. Epidural can be used as;

Epidural Anesthesia Epidural Analgesia

New Paradigm in RA vs GA
RA and GA are no longer considered as

alternative anesthesia, but instead as

complementary anesthesia.
This is especially true in pediatric where RA is essentially performed under GA. Combine of 2 techniques dramatically cut down the risk of both procedures.

Epidural guidelines 2010

The 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

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

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

Epidural technique

Human sensory dermatomes

FENTANYL
PROPOFOL

ANALGESIC HYPNOTIC RELAXATION Reduced Dose of - Fentanyl - Propofol - NDMR - LA

NDMR EPIDURAL

EARLY WAKE UP WITH NO PAIN

SEKIAN DAN TERIMA KASIH

SEMOGA ADA MANFAATNYA