NARCOTICS

Question 1

· Fentanyl

Answer 1

-Analgesic/sympathectomy dose during induction: Adults: 1-2 mcg/kg IV
-Adjunct c inhaled anesthetic: 12.5-50 mcg (used during DL and sudden changes in sx stimulation level)
o Onset: Rapid onset of 1-3 minutes and high lipid soluble (potent); Peak 3 minutes (if doing RSI on patient, must give 3 minutes before you induce to have peak effect)
o Duration: 30-60 min
o Precautions: Produces potentiation of benzodiazepines (apnea); decreased dose required of propofol; may produce chest wall rigidity; Inc ICP 6-9 mmHg; decrease dose in elderly d/t hepatic and albumin; normal dose in liver cirrhosis d/t CYP production unchanged. Up to 70% redux MAC.

Question 2

· Alfentanil (sometimes used for eye cases)

Answer 2

-Analgesia dose: 250/500 mcg IV
o Onset: 1.4 minutes (greater than fent and sufent) d/t Pka (more unionized);
DOA:15 minutes
o C/I: Acute dystonia in Parkinson’s; erythromycin;
o Precautions: cirrhosis and elderly will prolong E1/2 time; decrease MAC by 70%; only opiate to cause apnea; inc ICP in cerebral lesion; caution in renal failure

Question 3

· Remifentanil

Answer 3

-Induction dose: 0.5-1 mcg/kg (IBW)
-GA Infusion dose: 0.02 mcg - 2 mcg/kg/min (turn off 6 mins before breathing and give longer acting)
o Onset: 1.1 minutes (quickest);
duration: 5-10 minutes
o C/I: no intrathecal (glycine formation toxic to nerves)
o Precautions: decrease MAC by 90% (as potent as 1 MAC); synergistic vent depression with propofol; decrease dose in elderly and renal failure

Question 4

Sufentanil (We don’t use at ARMC, but you could use elsewhere for out rotations)

Answer 4

-Analgesia dose: 0.1-0.4 mcg/kg IV
-Induction/infusion dose: 0.5-1 mcg/kg IV or 0.2-0.5 mcg/kg/hr for infusion
-Spinal dose with C/S: 2.5-10 mcg intrathecal
-Labor dose: 2.5-7.5 mcg intrathecal
o Onset: In seconds with peak in 4 minutes; duration: 20 minutes
Precautions: Stop 45 minutes before case to ensure emergence; go down by 75% on MAC; caution with chronic renal failure

Question 5

· Morphine (Uncommon at ARMC)

Answer 5

-Post-op dose: 5- 20 mg IV
-Maintenance dose: 1-2 mg/hr IV
o Onset: 3 minutes with peak at 15 minutes; 2-4 hours duration

o C/I: Renal and liver pts d/t metabolite accumulation
o Precautions: Histamine release; decrease dose in elderly

Question 6

Dilaudid

Answer 6

o Dose Range: Calculate 0.02 mg/kg and give half up front after induction, then 0.2 every preceding hour besides the last hour. Usually no more than 2 mg during case. Also titrate to RR 12-20.
o Onset: 3 minutes with peak at 15 min; duration 2-4 hours
o C/I: GI obstruction and ileus
o Precautions: Active metabolite; Don’t overshoot c this med or you’ll be pushing Narcan at end.