Basic Anaesthesia Drugs - Opioids

Here is our brief guide to opioids in anaesthesia.
We cover morphine, fentanyl, alfentanil, remifentanil and iv oxycodone.
There are so many facts you can learn about these very effective and potentially lethal medications, but we want you to have a pragmatic framework in your first rotation in anaesthesia.
We go through the essentials!
Dose, onset, offsets special features, concerns and literally how we use these medications in anaesthesia practice.
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The information contained in this podcast is for medical practitioner education only. It is not and will not be relevant for the general public.
This contains general information about medical conditions and treatments. The information is not advice and should not be treated as such.
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Medical information can change rapidly, and the author/s make all reasonable attempts to provide accurate information at the time of filming. There is no guarantee that the information will be accurate at the time of viewing
The information provided is within the scope of a specialist anaesthetist (FANZCA) working in Australia.
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[@steveabraham3052]

I enjoyed the video, thank you for teaching. I had a question regarding the Fentanyl dosing… in my early experience with Fentanyl, I recall an incident where I administered 50 mcg IVP of I for analgesia & the patient developed chest wall rigidity followed by a period of apnea. I provided noxious stimulation to no avail initially. Just before I could administer the Naloxone, (of course I administered oxygen as well), he returned to spontaneous respirations. My practice of administering Fentanyl now has changed a little 🤪 But is this something you’ve experienced or are familiar with? Thank you again for your podcasts 👍🏾

[@JN-kk4nk]

Thanks a lot guys :)) you are amazing 😊

[@steveabraham3052]

I enjoyed the podcast! Question… when asked about what one would “watch out for with administration of Fentanyl?” I did not hear you speak of chest wall rigidity… I have experienced this phenomenon once when I bolused a patient with 50 mcg for pain. The patient wasn’t sensitive or allergic, but almost immediately had difficulty breathing, then went apneic. Just before I could administer the Naloxone, he returned to spontaneous respirations. Of course had already applied oxygen to him after providing noxious stimulation. This did in fact scare me, as I was a new provider at the time. I’ve learned my lesson and am a lot more cautious when “slamming” Fentanyl to my patients 🤪 is this something you’ve experienced?

[@ABCsofAnaesthesia]

great comment, because chest wall rigidity is such a poorly understood and potentially very serious side effect. I didn't mention it for fentanyl because in the 15yrs I've been practising I haven't had an episode with fentanyl. BUT I have had this occur many times with remifentanil. But glad to hear your experience as a caution and definitely good to be vigilant when using such fast acting high efficacy opioids!

[@tammybambini1096]

I like your ideas of Alfentanil as "diagnostic" tool when patients already had a large dose of potentially long-acting opioids ;) I mostly use it for regional anesthesia (when I have it available, most of the times now the hospitals I work for don´t have it, and I found I can do nerve blocks without local anesthetics and the patient is still doing fine - there is no difference if I do one prick with the local first or just use the "real" regional needle to puncture the skin) or in procedures like hysteroscopy that are not really painful postoperatively (especially in ambulatory patients, where I want to make sure they have no residual anesthetics on board on discharge). Dosing would be 0.5mg on induction (a laryngeal mask is not really painful), and another 0.5mg as needed.

[@tammybambini1096]

Strange to hear that in ANZ you use mostly Morphine for anesthesia - here in Germany we almost exclusively use it for postoperative pain, and even that is getting rare since we now mostly use Piritramide or Oxycodone for this indication. We usually use Sufentanil or Fentanyl for induction and intraoperative pain control. But not every hospital has Sufentanil available, and Fentanyl is still the medication of choice in cardiac cases - and maybe in kids. Personally I strongly prefer Sufentanil over Fentanyl (less dizzyness on induction, less context-sensitive half life, less nausea). In the last year I had two cases of Fentanyl-induced apnea after extubation (my bad, but I prefer to use high-opioid/no relaxant in laparoscopic operations, since some hospitals still don´t have NMT-monitoring/myoacelerometry and discourage the use of Sugammadex), where the patient initially was breathing fine and then stopped - never had experienced that when using Sufentanil.

[@ketaminekp]

So here in the Developing world, we don't use NMT as heavily as the west. It's not as useful as you might think. You can quite safely administer relaxants without NMT in a ASA I, II patient. Perhaps the whole high opioid thing was completely avoidable. Just my 2 cents

[@tammybambini1096]

@@ketaminekp thanks for the comment. I concede that I could have used muscle relaxants instead of pain-adapted doses of opioids - but given that the surgeons want perfect view and lots of room when doing laparoscopy until the end of the operation and then the next patient on the OR table within minimum time in combination with the long half-life of NDMR there are not many choices. Sugammadex use was frowned upon in that hospital, while also not having quantitative monitoring devices - and when you don´t do NMT at least at the end of the case (and either wait it out or give reversal agents) the patients end up having relaxation overhang, with decreased control of the small throat muscles that prevent aspiration after extubation, so not using NMT puts your patient at risk of postoperative pulmonal complications up to asphyxia...

[@tammybambini1096]

@@ketaminekp also just yesterday I had a patient who had (in an operation some years ago) an intraoperative awareness event due to high relaxant / low analgesic/hypnotic use, causing him now to delay seeking operative treatment with now a suboptimal chance of restitutio ad integrum...

[@bosrey7807]

My father in law was put on Remifentanil after he had 2 stents put in and he was also diagnosed with Covid. Now he's on a ventilator with a remifentanil drip. Why would they give him Remifentanil if it suppresses the respiratory rate, only to then put him on a ventilator? He also experienced a major blood pressure drop and we were all called to the ICU fearing he wouldn't make it. Is this also due to the Remifentanil?

[@tammybambini1096]

Not knowing the specifics of your fathers case (hope he did recover!) I can only answer in a general way: opioids in a low dose lets you tolerate the endotracheal tube without too much influencing the respiratory rate - and the ventilator is not only providing respirations, but also oxygen and a continuous positive pressure level inside the airway to keep the alveoli open, enabling transfer of oxygen into the body that a - maybe exhausted from so much strenous breathing work - patient might not be able to achieve on their own. Remifentanil is used because it can be finely dosed to just the level of endotracheal tube tolerance and sedation while having minimal side effects in that dosage, also the effects of Remifentanil disappear after only a few minutes compared to other opioids due to its short acting half life and nearly no context sensitive half life.

[@davidmwanakatwe5130]

Is it possible to give opiods intraoperative?

[@ABCsofAnaesthesia]

Yes that’s a common standard :) most patients having surgery would be given morphine or fentanyl along with a range of other analgesics as part of a pain management strategy

[@kyledeitz2760]

I’m a CRNA in the USA and I rarely give morphine. I usually stick with fentanyl, remifentanil, and dilaudid. Sometimes sufenta. Is it more common in Australia to use morphine intaoperative than dilaudid? I feel it’s the opposite in the USA.

[@joestevenson5568]

​​​@@kyledeitz2760Dilaudid sees comparatively little use outside the USA. I'm sure I remember reading that the US uses something like 95% of the global supply.

[@Themedicobhas]

nice

[@ABCsofAnaesthesia]

Thanks

[@randychenault1998]

Why would an opioid make breathing better???

[@tammybambini1096]

Because opioids - aside of treating pain - reduce stress and decrease pre- and afterload of the heart, thereby overall reducing oxygen consumption of the body - and by this the body has not to breathe that hard overall.