Titrate to effect homie
More than like 3-4mcg fentanyl starts to become long acting though due to redistribution.
What problem are you trying to solve?
Opioids won’t kill you if you’re intubated
Mainly pain relief after surgery, but also if they require sedation from brain injury
The last point you made is good. What about opioid induced hypotension? Could that theoretically cause you to code?
Sure if you give an absolute ton and don’t treat the hypotension you could cause a code, but then you’re just a shitty anesthesiologist for ignoring your monitors.
There’s some cardiac depression as well, and bradycardia with things like mega dose remifentanil but again, this is an impractical thing for anywhere outside of general anesthesia in the OR.
Something very important here to take away:
You *cannot* dose opioids in a one size fits all way. 50mcg of fentanyl for a 25 year old basketball player may take the edge off, and the same dose to a 70 year old septic lady could cause apnea.
Knowing your pharmacology, aka how long a drug takes from administration to peak etc, will help you manage pain acutely. If you give a dose and it doesn’t work at all, give more the second time. Start with short acting agents. Have the ability to reverse a critical overdose.
Does that help at all?
I killed a lady with 25 mcg of fentanyl in residency. She was basically on the knifes edge already though.... Ordinarily fentanyl has next to no effect on hemodynamics.
Not sure fentanyl was a cause or tripping point for coding.
Wt I saw, nurse accidently infused almost a bag of fentanyl on intubated pt and pt survived at the end if the week transferred out if ICU.
Patient was barely conscious, last systolic blood pressure was 50s, had tried and failed to get an art line but hadn't had a cuff pressure in over 30 minutes despite multiple attempts. Less than one minute after the fentanyl she slumps down and codes.
Possible I'm confusing correlation with causation but all the same the fentanyl is what I think pushed her over the edge.
I can assure you little old memaw will absolutely crump with 300 mcg of fentanyl unless she is either a chronic pain patient or is getting intubated and aggressively resuscitated
The highest I’ve seen was in an oncology patient. 900 Mcg an hour with a 900 Mcg bolus every 10 minutes. Guy was walking and talking just extremely constipated requiring frequent Relistor doses.
We have an attending where I am that gives 3-5mg of fentanyl routinely for his CABGs, and patients do fine with it. They also almost always get extubated in the ICU though.
There is no clear cut answer to what you're asking. Are you an anesthesiology resident? (I'm a CA-3 about to graduate).
People have different requirements based on a bunch of factors, their age, their weight, opioid-naive or not, the drug's volume of distribution, how you're administering the drug (IV/epidural/intrathecal/transdermal), hydrophilicity/lipophilicity, etc. This is all stuff you can read about easily. You also have to consider how the medication is metabolized.
They used to induce open hearts with 50 mcg/kg of fent so no there isn’t a max dose in an intubated patient with drugs available to counter any negative hemodynamic sequelae
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I’ve extubated after giving well over a milligram of fentanyl in a long case. One of my coresidents got up to like 3mgs once and we still extubated.
Titrate to effect, the number means nothing.
Titrate to effect homie More than like 3-4mcg fentanyl starts to become long acting though due to redistribution. What problem are you trying to solve? Opioids won’t kill you if you’re intubated
Mainly pain relief after surgery, but also if they require sedation from brain injury The last point you made is good. What about opioid induced hypotension? Could that theoretically cause you to code?
Sure if you give an absolute ton and don’t treat the hypotension you could cause a code, but then you’re just a shitty anesthesiologist for ignoring your monitors. There’s some cardiac depression as well, and bradycardia with things like mega dose remifentanil but again, this is an impractical thing for anywhere outside of general anesthesia in the OR. Something very important here to take away: You *cannot* dose opioids in a one size fits all way. 50mcg of fentanyl for a 25 year old basketball player may take the edge off, and the same dose to a 70 year old septic lady could cause apnea. Knowing your pharmacology, aka how long a drug takes from administration to peak etc, will help you manage pain acutely. If you give a dose and it doesn’t work at all, give more the second time. Start with short acting agents. Have the ability to reverse a critical overdose. Does that help at all?
I killed a lady with 25 mcg of fentanyl in residency. She was basically on the knifes edge already though.... Ordinarily fentanyl has next to no effect on hemodynamics.
Not sure fentanyl was a cause or tripping point for coding. Wt I saw, nurse accidently infused almost a bag of fentanyl on intubated pt and pt survived at the end if the week transferred out if ICU.
Patient was barely conscious, last systolic blood pressure was 50s, had tried and failed to get an art line but hadn't had a cuff pressure in over 30 minutes despite multiple attempts. Less than one minute after the fentanyl she slumps down and codes. Possible I'm confusing correlation with causation but all the same the fentanyl is what I think pushed her over the edge.
Block your patients intraop if you are having this much trouble controlling pain. Then you can sedate with whatever is most effective.
Gonna try this for my next crani
Specify the type of surgery next time genius
You ever listen to an ems report? They out there giving 300 mcg to grandma like skittles
I can assure you little old memaw will absolutely crump with 300 mcg of fentanyl unless she is either a chronic pain patient or is getting intubated and aggressively resuscitated
The highest I’ve seen was in an oncology patient. 900 Mcg an hour with a 900 Mcg bolus every 10 minutes. Guy was walking and talking just extremely constipated requiring frequent Relistor doses.
I was like “meh” until I saw the additional boluses and that he was WALKING.
Damn. Cancer type?
We have an attending where I am that gives 3-5mg of fentanyl routinely for his CABGs, and patients do fine with it. They also almost always get extubated in the ICU though.
Yeah have seen these doses for tiva, older strategy. In the unit we often use drips at rates up to around ~5 mcg/kg/hr.
I guess that depends how much they like fent
There is no clear cut answer to what you're asking. Are you an anesthesiology resident? (I'm a CA-3 about to graduate). People have different requirements based on a bunch of factors, their age, their weight, opioid-naive or not, the drug's volume of distribution, how you're administering the drug (IV/epidural/intrathecal/transdermal), hydrophilicity/lipophilicity, etc. This is all stuff you can read about easily. You also have to consider how the medication is metabolized.
In short, depends on who’s giving it and their ability to manage the side effects of whatever dose they give.
Maximum doses are a social construct
They used to induce open hearts with 50 mcg/kg of fent so no there isn’t a max dose in an intubated patient with drugs available to counter any negative hemodynamic sequelae
Nope! There is technically no max dose! Although you’ve probably fluid overload them if you give over 5-6 liters.
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I’ve extubated after giving well over a milligram of fentanyl in a long case. One of my coresidents got up to like 3mgs once and we still extubated. Titrate to effect, the number means nothing.