Absolutely agree with you. I have recently switched to using esmolol instead of fentanyl on induction and also see better hemodynamic stability (especially with long wait times between induction and incision).
I am a big believer in preemptive analgesia to help reduce opioid use intraoperatively. I'd be interested in your thoughts about other opioid sparing modalities such as precedex, ketamine, toradol, etc. I routinely use ketamine, although I am blessed to be in a facility currently that has 50mg premade syringes.
The improved hemodynamic stability following esmolol vs fentanyl is so nice (and probably underappreciated).
See my comment below for my usual approach to opioid-sparing. At my hospital, nearly all patients receive acetaminophen and dexamethasone preoperatively. Some will receive NSAIDs in preop depending on the surgeon's preference. I would favor giving most patients NSAIDs, such a ketorolac, in preop, but many surgeons still believe it has major bleeding risks.
The evidence seems clear that the risks of gabapentin outweigh any benefits.
What evidence is used for giving Decadron preop? It makes sense to me from theoretically. I receive crazy push-back when suggesting it. "It's going to cause perennially burning!" "Too much work for prep nurses with no benefit" "We've always given it at the end of surgery" 🙄 Is it diluted by pharmacy and given over 15+ mins as a prep order like with prep PO Tylenol? Is there a good RCT etc you could point me to?
That sounds like frustrating excuses at your institution. At my hospital, we are lucky that our preop nurses given dexamethasone. They tell all the patients that they can experience the perineal burning, and many do experience it. Though nI rarely hear any complaints about the side effect. Personally, I'm not sure I would want it while I was awake, but it is very convenient for our workflow.
For a good discussion, I recommend reading the 2020 PONV consensus statement, starting on page 11 with "Corticosteroids." Decadron has better PONV effects when given at the beginning of the anesthetic (does giving it in preop change this? I'm not sure). Aside from PONV, it is associated with improved pain scores, reduced length of stay, among some other benefits.
I agree that it wouldn't make much of a difference giving it pre-op vs on induction. I was just asking as a point of conversation/curiosity. I've heard of different protocols doing it that way. Even starting PO steroids before surgery (surgical implications there as well). But I am a strong believer that anesthesia has gotten so much safer, that we continue to improve by the little 0.1% things slowly around the edges. so if there is a benefit, we might as well. Hard to objectively prove those tiny improvements though, if they even exist. I am certainly not going to make the next big breakthrough in the field
I don't think giving it ahed of time improves efficacy. For us, it is part of our early recovery after surgery (ERAS) preoperative order set. It is nice for the anesthesiologists who can focus on one less medication to give during the case.
I like your writings ! How do you see the trajectory of opioid free anesthesia ? 10 years ago when I tried to spare opioids with clonidine or dexmetomidine, I was not satisfied. I didn't use esmolol then, maybe I should have pushed in this direction. Have you also tried with landiolol ? Do you use alpha agonists ? thanks
I see opioid-sparing anesthesia gaining ground; I am less certain about opioid-free anesthesia. In my own practice, I can sometimes get away without opioids for shorter general cases and many MAC cases, but that is very dependent on how well the surgeons give local anesthesia. I wish there was a larger push to use long-acting opioids from the start of cases. Methadone seems promising even for outpatient surgeries and may be a way to minimize opioid use.
Landiolol looks nice. Unfortunately, we don't have it at my hospital, and I haven't used it before. I imagine it would have a similar benefit to esmolol for intubation.
My usual general anesthesia analgesic approach is as follows. I rarely use fentanyl. I use esmolol and a small amount of ketamine with propofol for intubation. I give hydromorphone prior to incision. Usually, this is the only opioid I need to give. Ideally, I can titrate further hydromorphone to the respiratory rate if I can get the patient spontaneously breathing. If the hemodynamics tolerate dexmedetomidine, I love giving it, but I use it on less than half of my cases due to blood pressure or heart rate constraints.
When someone is initially hypertensive, my first response is to increase volatile agent or propofol. If I need more, then I usually give esmolol or dexmedetomidine before giving more opioids. For longer cases, I like to re-dose a small amount of ketamine hourly.
What are your thoughts on the very theoretical question of "Are we perhaps not contributing to a 'wind up/central sensitization' effect if we are not treating pain under GA, and just controlling SNS response?" I think I likely practice very similar to you and wonder as you put in your post: Do we need to treat pain under general anesthesia? The wind up question seems plausible to me and I don't necessarily have a good response when it's posed to me.
That’s an interesting question and not something I have specifically looked into. It seems clear from looking at regional and spinal anesthesia that patients experience less postop pain when those sensations are blocked from ever going to the spinal cord. As I understand it, that type of anesthetic would prevent windup from occurring.
When looking at esmolol in this context, I am reassured that by the fact that these patients use less opioids postop. That would suggest that windup, if it is happening, is less significant than any avoidance of opioid induced hyperalgesia. But perhaps if we shifted primarily to treating with sympatholytics instead of opioids we would see more windup. I will keep this in mind as a future topic.
One of the FDA indications is for the “control of perioperative tachycardia and hypertension.” That definitely has you covered.
Everywhere I have worked, esmolol has come in a 100 mg vial at 10 mg/mL. For most adults, I give 50 mg with the induction agent and then another 50 mg about a minute later unless the heart rate is less than 55-60. For old, frail, or tiny patients I’ll usually give about half as much.
-
One of the hospitals I trained at would run epinephrine infusions routinely on hip replacement patients under spinal/epidural anesthesia. I haven’t seen routine epi or norepinephrine infusions outside of that practice. Personally, I have a low threshold for reaching for norepinephrine. I think it is an excellent drug and it can certainly be administered through a peripheral IV for short durations. In the US, our main vasopressors (outside of the cardiac OR) are phenylephrine and ephedrine which everyone has pre-diluted in syringes.
Thanks for the explanations. We have pre-diluted ephedrine syringes. I use them often. Especially when I have low MAP and low HR. But we use a ton of low dose norepinephrine as I describe in my note. Basically (don’t roll eyes) we dilute 8 mg in a 500 ml bag. And we draw 60 ml syringes from this bag. Then we use it at 20-40-60 ml/h speed. Also one of advantage is the speed of recovery of the MAP with these kind of outputs
I think so yes. It began in obstetrics to manage AP during C section and this strategy was shared to other operating rooms with the idea to compensate for the vasodilation due to anesthetics. Once people have observed that at low concentrations it was safe the burden of the central vein access was gone to use norepinephrine which is better than phenylephrine IMHO
That's really good to know. Where I trained, it was standard practice to use a phenylephrine infusion on all C section patients following the spinal. Most would be titrated to zero an hour in. It worked great for preventing the hypotension.
Absolutely agree with you. I have recently switched to using esmolol instead of fentanyl on induction and also see better hemodynamic stability (especially with long wait times between induction and incision).
I am a big believer in preemptive analgesia to help reduce opioid use intraoperatively. I'd be interested in your thoughts about other opioid sparing modalities such as precedex, ketamine, toradol, etc. I routinely use ketamine, although I am blessed to be in a facility currently that has 50mg premade syringes.
The improved hemodynamic stability following esmolol vs fentanyl is so nice (and probably underappreciated).
See my comment below for my usual approach to opioid-sparing. At my hospital, nearly all patients receive acetaminophen and dexamethasone preoperatively. Some will receive NSAIDs in preop depending on the surgeon's preference. I would favor giving most patients NSAIDs, such a ketorolac, in preop, but many surgeons still believe it has major bleeding risks.
The evidence seems clear that the risks of gabapentin outweigh any benefits.
What evidence is used for giving Decadron preop? It makes sense to me from theoretically. I receive crazy push-back when suggesting it. "It's going to cause perennially burning!" "Too much work for prep nurses with no benefit" "We've always given it at the end of surgery" 🙄 Is it diluted by pharmacy and given over 15+ mins as a prep order like with prep PO Tylenol? Is there a good RCT etc you could point me to?
That sounds like frustrating excuses at your institution. At my hospital, we are lucky that our preop nurses given dexamethasone. They tell all the patients that they can experience the perineal burning, and many do experience it. Though nI rarely hear any complaints about the side effect. Personally, I'm not sure I would want it while I was awake, but it is very convenient for our workflow.
For a good discussion, I recommend reading the 2020 PONV consensus statement, starting on page 11 with "Corticosteroids." Decadron has better PONV effects when given at the beginning of the anesthetic (does giving it in preop change this? I'm not sure). Aside from PONV, it is associated with improved pain scores, reduced length of stay, among some other benefits.
https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/endorsed-documents-fourth-consensus-guidelines-postop-nausea-vomiting.pdf
Hello,
I do 8 mg of dexamethasone to nearly all my patients are aslept for PONV, analgesia and anti-inflammatory effet, especially in cancer patients.
I give it in the induction sequence.
I have never worked in the US, so I would be keen to understand why is it useful for you to give it before the patient is aslept.
Thanks a lot
I agree that it wouldn't make much of a difference giving it pre-op vs on induction. I was just asking as a point of conversation/curiosity. I've heard of different protocols doing it that way. Even starting PO steroids before surgery (surgical implications there as well). But I am a strong believer that anesthesia has gotten so much safer, that we continue to improve by the little 0.1% things slowly around the edges. so if there is a benefit, we might as well. Hard to objectively prove those tiny improvements though, if they even exist. I am certainly not going to make the next big breakthrough in the field
I don't think giving it ahed of time improves efficacy. For us, it is part of our early recovery after surgery (ERAS) preoperative order set. It is nice for the anesthesiologists who can focus on one less medication to give during the case.
Ok thanks
I like your writings ! How do you see the trajectory of opioid free anesthesia ? 10 years ago when I tried to spare opioids with clonidine or dexmetomidine, I was not satisfied. I didn't use esmolol then, maybe I should have pushed in this direction. Have you also tried with landiolol ? Do you use alpha agonists ? thanks
I see opioid-sparing anesthesia gaining ground; I am less certain about opioid-free anesthesia. In my own practice, I can sometimes get away without opioids for shorter general cases and many MAC cases, but that is very dependent on how well the surgeons give local anesthesia. I wish there was a larger push to use long-acting opioids from the start of cases. Methadone seems promising even for outpatient surgeries and may be a way to minimize opioid use.
Landiolol looks nice. Unfortunately, we don't have it at my hospital, and I haven't used it before. I imagine it would have a similar benefit to esmolol for intubation.
My usual general anesthesia analgesic approach is as follows. I rarely use fentanyl. I use esmolol and a small amount of ketamine with propofol for intubation. I give hydromorphone prior to incision. Usually, this is the only opioid I need to give. Ideally, I can titrate further hydromorphone to the respiratory rate if I can get the patient spontaneously breathing. If the hemodynamics tolerate dexmedetomidine, I love giving it, but I use it on less than half of my cases due to blood pressure or heart rate constraints.
When someone is initially hypertensive, my first response is to increase volatile agent or propofol. If I need more, then I usually give esmolol or dexmedetomidine before giving more opioids. For longer cases, I like to re-dose a small amount of ketamine hourly.
You sir are a gentleman and a scholar
What are your thoughts on the very theoretical question of "Are we perhaps not contributing to a 'wind up/central sensitization' effect if we are not treating pain under GA, and just controlling SNS response?" I think I likely practice very similar to you and wonder as you put in your post: Do we need to treat pain under general anesthesia? The wind up question seems plausible to me and I don't necessarily have a good response when it's posed to me.
That’s an interesting question and not something I have specifically looked into. It seems clear from looking at regional and spinal anesthesia that patients experience less postop pain when those sensations are blocked from ever going to the spinal cord. As I understand it, that type of anesthetic would prevent windup from occurring.
When looking at esmolol in this context, I am reassured that by the fact that these patients use less opioids postop. That would suggest that windup, if it is happening, is less significant than any avoidance of opioid induced hyperalgesia. But perhaps if we shifted primarily to treating with sympatholytics instead of opioids we would see more windup. I will keep this in mind as a future topic.
other questions since this intrigue me very much
1) in the official indications of the drug is it ok and allowed to use it besides cardio-vascular diseases and pheochromocytoma ?
2) how do you prepare your syringe for an straightforward use in the OR, what is your usual output ?
And do you use small dose norepinephrine to maintain hemodynamics for more severe patients ? (in french here: https://nfkb.substack.com/i/151510472/noradrenaline-a-16-gammasml-le-retour )
One of the FDA indications is for the “control of perioperative tachycardia and hypertension.” That definitely has you covered.
Everywhere I have worked, esmolol has come in a 100 mg vial at 10 mg/mL. For most adults, I give 50 mg with the induction agent and then another 50 mg about a minute later unless the heart rate is less than 55-60. For old, frail, or tiny patients I’ll usually give about half as much.
-
One of the hospitals I trained at would run epinephrine infusions routinely on hip replacement patients under spinal/epidural anesthesia. I haven’t seen routine epi or norepinephrine infusions outside of that practice. Personally, I have a low threshold for reaching for norepinephrine. I think it is an excellent drug and it can certainly be administered through a peripheral IV for short durations. In the US, our main vasopressors (outside of the cardiac OR) are phenylephrine and ephedrine which everyone has pre-diluted in syringes.
Thanks for the explanations. We have pre-diluted ephedrine syringes. I use them often. Especially when I have low MAP and low HR. But we use a ton of low dose norepinephrine as I describe in my note. Basically (don’t roll eyes) we dilute 8 mg in a 500 ml bag. And we draw 60 ml syringes from this bag. Then we use it at 20-40-60 ml/h speed. Also one of advantage is the speed of recovery of the MAP with these kind of outputs
That's really interesting. Is that a common practice in France?
I think so yes. It began in obstetrics to manage AP during C section and this strategy was shared to other operating rooms with the idea to compensate for the vasodilation due to anesthetics. Once people have observed that at low concentrations it was safe the burden of the central vein access was gone to use norepinephrine which is better than phenylephrine IMHO
That's really good to know. Where I trained, it was standard practice to use a phenylephrine infusion on all C section patients following the spinal. Most would be titrated to zero an hour in. It worked great for preventing the hypotension.