Fentanyl in GA and RA_edit
Transcript of Fentanyl in GA and RA_edit
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The Role of Fentanylin GA and RA.
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Since than (1846) Evolution of Anesthesia
from Ether to Fentanyl
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HypnoticAnalgesiaRelaxation
1846 19261990 2000
BalancedAnesthesia 1926
(Lundy)
Unconsciousness hypnoticAntinociceptive analgesia
Relaxation muscle relaxant
HalothaneN2O
Pavulon/ curare
BalancedAnalgesia
EraODC
80 years 75 years
PremedicationSA/ ScopolamineMo. or Pethidine
PremedicationSA
Mo. or Pethidine
Im worried that Iwont wake up
Main Goal of Anesthesia isto Bring Back Patients
Alive
No premedicationNo SA
No opiates
Not onlyAwake up and Analgesia,
but alsofull alert and can walk
home
Im worried tohave PAIN,
After surgery
Save Anesthesia
EtherOnly
EraModern Anesthesia
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ETHER
Except Ether(1848) as a very old andtypical anesthetic agent which mayproduce, AMNESIA( HYPNOTIC)ANALGESIA & RELAXATIONno otheranesthetic agent may produce triadanesthesia. But it has many disadvantages.
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The feat earned Morton theepitaph in Massachusetts
The Inventor of anesthetic inhalationBy whom pain in surgery was annulled
Since whom science has control of PAINBefore whom, surgery as agony
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John Lundy (1926) from Mayo Clinic firstintroduced BALANCED ANESTHESIA
Antinociceptive analgesicUnconsciousness hypnotic
Relaxation muscle relaxant
BALANCED ANESTHESIA
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In 75-90 our typical anesthesiaNitrous OxideFlouthane
Pancuronium Br /CurareStill has some disadvantages
BALANCED ANESTHESIA
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Since than, scientis looking forIdeal:
1. Analgesic2. Hypnotic3. Muscle relaxant
BALANCED ANESTHESIA
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Strong ANALGESIC FENTANYL
Good HYPNOTIC PROPOFOL
RELAXATION N D M R
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Fentanyl
Discovered in 1963 by Dr. PaulJanssen
Synthethic opioidStrong Opioid 100x to MorphinePure agonistFentanyl is the reference analgesic inanaesthesiaNo ceiling effect
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Mu1 : analgesia (supraspinal, spinal), euforia,
miosis, bradikardi, hipotermi,retensi urine.
Mu2 : analgesia (spinal), depresi ventilasi,
konstipasi (bermakna).
Kappa : analgesia (supraspinal, spinal), disforia,sedasi, miosis, diuresis.
Delta : analgesia (supraspinal, spinal), depresiventilasi, konstipasi (minimal),retensi urine.
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Modulation
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Opioid mechanisms
Substance Petc
Spinal cord neurone
C-fibre
Descendingcontrols
To the brain
Glutamate
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Opioid mechanisms
Substance Petc
Spinal cord neurone
C-fibre
Descendingcontrols
To the brain
Opioid
Glutamate
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Fentanyl
IndicationsFentanyl is used in the treatment of acute
pain and to depress breathing in patientsbeing ventilated . It may also be given as aninfusion under the skin in palliative care
patients who have intolerable side effectsfrom Morphine.
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Fentanyl Dosing For Our
Protocols50-100mcg IV or 1-2 mcg/kgMay repeat dose every 5 minutes until max of
3mcg/kg. Pay special attention to your dosing this is theonly medication we have that is given in Micro-
grams (mcg).
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Fentanyl vs MorphineANALGESIC MEDICATION OPTIONS(Choose one) Fentanyl 50-100 mcg IV (1-2 mcg/kg)
may repeat dose every 5 minutes until maximumof 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
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Fantanyl Dosing (Continued)
Fentanyl supplied in ampules of 100mcg/2mlor 250mcg/5ml
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Fentanyl Dosing ( Continued)
So what's the concentrationfor 100mcg/2ml???50mcg/ml Right!For 250mcg/5ml???
50mcg/ml You got it!
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Fentanyl
PharmacokineticsIntramuscularOnset 7-15 minutes
Peak 15 minutesDuration 1-2 hours
IntravenousOnset few minutesPeak few minutesDuration 30-60 minutes
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Fentanyl PrecautionsOver SedationRespiratory Depression RR 12 with
sedationPin point pupil
Respiratory depression from opioids is manifested by:a reduced drive to breathreduced rate,often associated with sighing pattern.
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Fentanyl
Precautions/Warnings Cont.Alcohol and Drugs of Abuse - May be expected tohave additive CNS depressant effects when used
in conjunction with alcoholCardiac Disease may produce bradycardiashould be used with caution in patients withknown bradyarrhytmias.Hepatic or Renal Disease Caution because of the hepatic metabolism and renal excretion of Fentanyl.
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Fentanyl Contraindications
Intermittent painRespiratory depression
Acute or severe asthmaParalytic ileus - paralysis of the intestineKnown hypersensitivity
Opioid induce Hyperalgesia
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Fentanyl Side Effects Common &Uncommon
CommonRash, Nausea, Vomiting , Drowsiness, DryMouth, Dizziness, Difficulty Urinating,Constipation (prolonged use), Constricted pupils
UncommonRigid chest wall, Decreased Breathing,
Confusion, Itching, Slowing or Elevated HR,ABD pain.
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Considerations
Parenteral dose may be given diluted orundilutedAdminister IV over 1 to 2 minutesProtect from lightClosely monitor vital signsRespiratory depression may out last the
analgesic effectEffects may be reversed by naloxon(Narcan)
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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 hepaticfailure.
Reserve for pain management outside the cardiacsetting.
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Fentanyl In Summary
Fentanyl is a potent analgesicDose is 1-2 mcg/kgReversal agent is Naloxon (Narcan)
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Barier in using opioid as a
strong analgesicwhen mention about pain it side effect iscoming up not the benefits Sedation
Nausea /VomitingConstipation
Pruritus
Respiratory -
depressionAddictionTolerance
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Role of Fentanyl inAnesthesia : 1. Premedication
Premedication 50 to 100 mcg iv or im
2. General AnesthesiaLow (2mcg/kg), Moderate(2-20) or High dose (20-50)
3. Adjunct to General Anesthesia with inhalation4. 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
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Propofol
Before introduction of protofal, thiopental(ultra short acting barbitural) is commonlyused.Good for induction expect for its painfulduring the injection, can be overcome by Ledocain 1 mg/Kg BW Fentanyl 1 ug/Kg BW
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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 fractionGood for supporting bacterial growth, sosterilitation is very important.
Propofol
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Propofal primary act as hypnotic, has noanalgesia.Decreas CBF and CMRO2 ICPThis effect equal with thiopentalIt has antiemetic effect
Rapid onset 30 optimal 2 duration about 10
Propofol
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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.
Propofol as strong hypnotic Fentanyl, Sufentanil, Alfentanil, as strong analgesics Rocuronium, Vecuronium, Atracurium, etc. as NDMR
TIVA + Epidural Analgesia
T I V A
N O
! ! !
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Epidural Anesthesia
Epidural is the main modality inAcute Pain Service.
Epidural can be used as;Epidural Anesthesia
Epidural Analgesia
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Epidural guidelines 2010The 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
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Grass JA, Problems in Anesthesia1998,10(1):45-70
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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 9Lower abdominal laparatomy ; Th 10 11Pelvic sugery/ Lower limb surgery ; L 2-4
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Epidural technique
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H d
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Human sensory dermatomes
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Reduced Dose of - Fentanyl- Propofol- NDMR
- LA
FENTANYL
PROPOFOLN D M R
EPIDURAL
ANALGESIC
RELAXATION
HYPNOTIC
EARLY WAKE UP WITH NO PAIN
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SEKIAN DAN TERIMA
KASIHSEMOGA ADA MANFAATNYA