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FENTANIL AND REMIFENTANIL
charliececi:
hi, I have the habit to start the GA by using fentanil 2mcg/kg for the induction and then start the remifentanil infusion. I feel not safe to start with remifentanil ( I had an episode of tremendous stiffness) do you think this practice is correct? Do you have any clinical evidence to support or not this practice ?( I never had problems)
thanks
Simone
yogenbhatt1:
HI,
Out here in India, we do not have Remifent. We had Sufent some time back, not available again.
I had a very bad experience with Sufent. The elderly patient was given Sufent, the dose was more than we actually wanted to give( Almost twice over).
This patient developed such tight stiffness that we just could not ventilate the patient. It was a frightening experience in an old cardiac patient. We had to paralyse her to ventilate her and had to give vaso pressors to a patient posted for spine surgery, where we would like hypotension.
jafo1964:
Chest wall rigidity is common to all phenopiperidine group of narcotics which includes all the nil's - Fenta, Sufenta, Alfenta and remifenta.
So theorotically similar rigidity can occur with all agents in the susceptible patient. this can be minimized by administration in a diluted form.
Theorotically there is no advantage of starting with fentanyl and switching to remifentanyl.
Thankfully both are mu receptor agonists and can be compatibly used.
Cases have been documented were chest wall rigidity led to inability to ventilate and also to hypoxic cardiac arrest.
although rare it can be a very dangerous complication.
On the converse when you work with remifentanyl you need to worry about post-op analgesia. As soon as you stop remi( which is done to allow the patient to awaken from anaesthesia) the patient will experience the full pain. To take care of this, longer acting narcotic must be started much before Remi is stopped. This longer acting could be Morphine or Fenta
I have no working experience with Remi but theorotically this seems to be the take on these drugs
regs
dejswa:
Starting with fentanyl for that reason doesn't make much sense.
I use remi all the time. Clinically used doses are 'potent' because it is a short acting drug. Thus, you can get some stiffness, but no different than with any other of the narcotics listed below.
I always mix with propofol and have no problems anyway - 1 mg remi in 50 cc propofol.
Besides, that is what rocuronium or other relaxant is for.
But generally - no relaxant needed with 10cc of the above mixture. (but maybe a little ephedrine).
Regarding end of infusion. You can add some other narcotic or not.
I find that meperidine is great. Knocks out shivering which is more common when recovering from remi infusion.
Pingwin:
1 mg of Remi in Propofol? Are You sure about that dose? Anyway - is it ok to mix these drugs? We use Fentanyl and then - Remifentanyl, You are all right about the stiffness, but You need to give drugs slowly - whenever You push them with a high speed, You get troubles.
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