Preoperative Fentanyl Infusion with Pharmacokinetic Simulation for Anesthetic and Perioperative Management of an Opioid-Tolerant Patient

Davis, Julia; Johnson, Kenward B.; Egan, Talmage D.; Vézina, Daniel P.; Snell, Timothy E.; Swenson, Jeffrey D.

doi:10.1213/01.ane.0000090151.13573.42

Cited by 9 publications

(9 citation statements)

References 6 publications

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“…reported that pain scores were lower than the pre‐treatment levels for up to 3 h of administration of remifentanil, which is consistent with our findings. In the clinical setting of pain relief, tolerance to opioids could develop in a few days or even hours after the administration . Additionally, it is demonstrated that pain scores during labor are positively related to cervical dilation (i.e.…”

Section: Discussionmentioning

confidence: 99%

Perinatal outcomes: Intravenous patient‐controlled fentanyl versus no analgesia in labor

Miyakoshi

Tanaka

Morisaki

et al. 2012

J of Obstet and Gynaecol

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Section: Discussionmentioning

confidence: 99%

Perinatal outcomes: Intravenous patient‐controlled fentanyl versus no analgesia in labor

Miyakoshi

Tanaka

Morisaki

et al. 2012

J of Obstet and Gynaecol

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“…Some anesthetists suggest ‘front loading’ with relatively large doses of opioids at induction, with others favoring half of the estimated dose at induction and titrating the rest during the remainder of the procedure (5). Techniques to determine an individual patient’s requirements have been described in adults and include titration of analgesia to clinical observation of respiratory rate and pupil size, and the use of fentanyl infusion to apnea (62,63).…”

Section: Intraoperative Considerationsmentioning

confidence: 99%

Perioperative management of the child on long‐term opioids

Geary

Negus

Anderson

et al. 2011

Pediatric Anesthesia

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The strategies used to manage children exposed to long-term opioids are extrapolated from adult literature. Opioid consumption during the perioperative period is more than three times that observed in patients not taking chronic opioids. A sparing use of opioids in the perioperative period results in both poor pain management and withdrawal phenomena. The child's pre-existing opioid requirement should be maintained, and acute pain associated with operative procedures should be managed with additional analgesia. This usually comprises short-acting opioids, regional or local anesthesia, and adjuvant therapies. Long-acting opioids, transdermal opioid patches, and implantable pumps can be used to maintain the regular opioid requirement. Intravenous infusion, nurse controlled analgesia, patient-controlled analgesia, or oral formulations are invaluable for supplemental requirements postoperatively. Effective management requires more than simply increasing opioid dose during this time. Collaboration of the child, family, and all teams involved is necessary. While chronic pain or palliative care teams and other staff experienced with the care of children suffering chronic pain may have helpful input, many pediatric hospitals do not have chronic pain teams, and many patients receiving long-term opioids are not palliative. Acute pain services are appropriate to deal with those on long-term opioids in the perioperative setting and do so successfully in many centers. Staff caring for such children in the perioperative period should be aware of the challenges these children face and be educated before surgery about strategies for postoperative management and discharge planning.

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“…Using pharmacokinetic simulation software, 68 the authors determined that the effect‐site concentration of fentanyl achieved at the time of unresponsiveness was 293 ng/mL and that to maintain a plasma level of fentanyl corresponding to 25% of that value, an infusion rate of 33 µg/kg/minute would be required. This value was chosen based upon previous data which indicated that the minimum effective plasma concentration necessary to provide adequate analgesia is approximately 25 to 30% of that concentration associated with significant respiratory depression 68–70 . A patient‐controlled analgesia (PCA) pump was programmed to allow a total hourly dose of 33 µg/kg/hour by delivering fentanyl at a basal rate of 16.5 µg/kg/hour with a lockout interval of 15 minutes and a demand dose of 250 µg.…”

Section: Intraoperative Concerns In the Opioid‐tolerant Patientmentioning

confidence: 99%

“…This value was chosen based upon previous data which indicated that the minimum effective plasma concentration necessary to provide adequate analgesia is approximately 25 to 30% of that concentration associated with significant respiratory depression. [68][69][70] A patient-controlled analgesia (PCA) pump was programmed to allow a total hourly dose of 33 mg/kg/hour by delivering fentanyl at a basal rate of 16.5 mg/kg/hour with a lockout interval of 15 minutes and a demand dose of 250 mg. One hour after arrival at the intensive care unit, the patient was easily awakened and was able to follow commands. The patient, according to the authors, reported being satisfied with her quality of analgesia and denied any recall or pain associated with the operative procedure.…”

Section: Intraoperative Analgesic Requirementsmentioning

confidence: 99%

Perioperative and Intraoperative Pain and Anesthetic Care of the Chronic Pain and Cancer Pain Patient Receiving Chronic Opioid Therapy

Rozen

Grass

2005

Pain Practice

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The expanding role of the anesthesiologist as a "perioperative physician" places ever-increasing demands upon his or her clinical skills and knowledge. One area of growing concern for the anesthesiologist involves the perioperative assessment and management of the opioid-tolerant chronic pain patient. Opioids occupy a position of unsurpassed clinical utility for the treatment of many types of painful conditions. Coupled with noticeable shifts in physician attitudes that have occurred in recent years regarding the use of opioids for the treatment of benign and malignancy-related pain, many more patients are presenting for surgical procedures who are opioid tolerant. It is important therefore that the practicing anesthesiologist become familiar with the currently available opioid formulations, including drug interactions and side effects, in order to better plan the patient's perioperative anesthetic needs and management. Unfortunately, there is a lack of scientifically rigorous studies in this important area, and most of the information must be derived from anecdotal reports and personal experience of anesthesiologists working in this field. In this review, we shall discuss some aspects of current chronic pain management, the newer forms of opioid administration which may be unfamiliar to the anesthesiologist, as well as clinical aspects of opioid use and tolerance including the impact it may have on perioperative anesthetic management.

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Preoperative Fentanyl Infusion with Pharmacokinetic Simulation for Anesthetic and Perioperative Management of an Opioid-Tolerant Patient

Abstract: A preinduction fentanyl infusion used in conjunction with pharmacokinetic simulation can be a useful tool for assessing individual limits of opioid tolerance, as well as determining an appropriate dose for acute pain management in opioid-tolerant patients.

Cited by 9 publications

References 6 publications

Perinatal outcomes: Intravenous patient‐controlled fentanyl versus no analgesia in labor

Perinatal outcomes: Intravenous patient‐controlled fentanyl versus no analgesia in labor

Perioperative management of the child on long‐term opioids

Perioperative and Intraoperative Pain and Anesthetic Care of the Chronic Pain and Cancer Pain Patient Receiving Chronic Opioid Therapy

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