Intravenous Administration Of Fentanyl Research Articles

A Case of True Allergy to Amide Local Anesthetics in a Parturient

IgE-mediated hypersensitivity reactions to amide local anesthetics (LAs) are very rare events in anesthesia practice. When such a reaction occurs, anesthesiologists are often left with numerous confounding causes of adverse e after LA administration. Most times, such reactions result from systemic toxicity or non-hypersensitivity reactions. In the event of a true allergy to LA molecules, subsequent administration of the same drug can lead to life-threatening complications. Herewith, we report the successful diagnosis of LA allergy in a parturient who had a history of anaphylaxis following the administration of subarachnoid block with an unknown drug elsewhere. She presented to our institute for her second cesarean section. Skin prick testing was done after a dermatology consultation, which revealed a positive response to lignocaine, bupivacaine, and ropivacaine (preservative-free). She was taken up for elective cesarean section under general anesthesia with complete avoidance of LAs. Postoperative analgesia was instituted with intravenous patient-controlled fentanyl administration. The procedure and recovery were uneventful and both mother and baby were discharged without any issues.

Investigating Deep Sedation With Intravenous Ketamine in Spontaneous Respiration During Pulsed-Field Ablation

The authors report their experience of a protocol for deep sedation with ketamine in spontaneous respiration during the pulsed-field ablation (PFA) of atrial fibrillation (AF). Observational, prospective, nonrandomized fashion. Single-center hospitalized patients. All consecutive patients undergoing PFA of AF. Patients undergoing deep sedation with intravenous ketamine. The authors' sedation protocol involves the intravenous administration of fentanyl (1.5 µg/kg) and midazolam (2 mg) at low doses before local anesthesia with lidocaine. A ketamine adjunct (1 mg/kg) in 5-minute boluses was injected about 5 minutes before the first PFA delivery. The authors enrolled 117 patients (age=59 ± 10 y, 74.4% males, body mass index=27.6 ± 5 kg/m2, fluoroscopy time=24 ± 14 minutes, skin-to-skin time=80 ± 40 minutes and PFA LA dwell time=24 ± 7 minutes). By the end of the procedure, pulmonary vein isolation had been achieved in all patients using PFA alone. The mean time under sedation was 54.9 ± 6 minutes, with 92 patients (79%) being sedated for <1 hour. A satisfactory Ramsay Sedation Scale level before ketamine administration was achieved in all patients, except one (80.3% of the patients with rank 3; 18.4% with rank 2). In all procedures, the satisfaction level was found acceptable by both the patient and the primary operator (satisfactory in 98.2% of cases). All patients achieved a Numeric Rating Scale for Pain ≤3 (none or mild). No major procedure or anesthesia-related complications were reported. The authors' standardized sedation protocol with the administration of drugs with rapid onset and pharmacologic offset at low doses was safe and effective, with an optimal degree of patient and operator satisfaction.

Comparison of Changes in Chest Wall Mechanics and Respiratory Timing Between Patient-Controlled Epidural Analgesia and Intravenous Patient-Controlled Analgesia After Laparoscopic Gastrectomy: A Randomized Controlled Trial.

Upper abdominal surgery is associated with postoperative diaphragmatic dysfunction. Whether patient-controlled epidural analgesia (PCEA) is superior to intravenous patient-controlled analgesia (IV-PCA) in preventing postoperative diaphragmatic dysfunction is still unclear in laparoscopic gastric surgery. Sixteen patients undergoing laparoscopic gastrectomy randomly received either PCEA or IV-PCA. The primary outcomes were the change in chest wall mechanics and respiratory timing, measured by respiratory inductive plethysmography(Respitrace; Ambulatory Monitoring Inc., Ardsley, New York, United States) before and after surgery, and analyzed by a data acquisition system (PowerLab; ADInstruments, Dunedin, New Zealand). Inspiratory time (Ti), expiratory time (Te), total respiratory cycle time (Ttot), proportion of inspiratory time over total respiratory cycle time (Ti/Ttot), respiratory rate (RR), and abdominal contribution to tidal volume (AB/VT [%]) were calculated from the stored data. AB/VT, relative volume contribution of diaphragm to tidal breathing, represents an index of diaphragmatic function.Because the diaphragm is the main contributor to tidal volume, decreases in AB/VT indicate diaphragm dysfunction. Changes in outcomes over time between the two groups were analyzed using a linear mixed model, and two-sided p values < 0.05 were considered statistically significant. The secondary outcomes were postoperative pain score(visual analog scale (VAS)), bowel function recovery, and hospital stay duration. Postoperative AB/VT in the IV-PCA group was significantly decreased compared to preoperative levels. AB/VT in the PCEA group was significantly higher than the IV-PCA group on postoperative day (POD) 1. Change in AB/VT over time between the PCEA group and the IV-PCA group differed significantly (p = 0.01). A decrease of AB/VT during POD 1 to 3 was observed in the IV-PCA group but not in the PCEA group. As for respiratory timing, there were significant increases in RR with a reduction of Te and Ttot compared to preoperative levels on POD 1 in the PCEA group. There were significant decreases in RR and Ti/Ttot with an increase of Te and Ttot compared to preoperative levels on POD 1 in the IV-PCA group. There was a significant difference in the change of the Ttot over time between the two groups (p = 0.046). There were no significant differences in the changes of Te, Ti/Ttot, Ti, and RR over time between the two groups. There was no significant difference in VAS over time at rest and mobilization, recovery of bowel function, and hospital stay between the two groups. Continuous ropivacaine infusion with PCEA partially attenuated diaphragmatic dysfunction after laparoscopic gastrectomy, while pain relief by continuous intravenous administration of fentanyl could not attenuate diaphragmatic dysfunction. This suggests that PCEA might ameliorate postoperative diaphragmatic dysfunction after laparoscopic gastrectomy.

Use of Liquid Chromatography--Tandem Mass Spectrometry to Quantify and Confirm the Fentanyl Metabolite N-[1-(2-Phenethy-4-Piperidinyl)] Maloanilinic Acid in Equine Urine for Doping Control.

Fentanyl, a powerful synthetic mu opioid receptor agonist, is banned in equine sports by the Association of Racing Commissioners International and the Fédération Équestre Internationale. The presence of fentanyl in equine blood has been confirmed during routine post-race screening for doping substances in the authors' laboratory. While fentanyl can be detected and confirmed in blood, it is rapidly metabolized, and screening for the metabolite N-[1-(2-phenethy-4-piperidinyl)] maloanilinic acid (PMA) in equine urine is expected to allow for a longer detection time. In this study, a quantitative and confirmatory liquid chromatography--tandem mass spectrometry (LC-MS-MS) method was developed for PMA analysis in equine urine. PMA was extracted by solid phase extraction, separated on a C18 column and detected using a triple quadrupole mass spectrometer. The mass spectrometer was operated in positive-ion mode, and multiple reaction monitoring was used to monitor product ions m/z 188, m/z 281 and m/z 323. The method was validated for extraction recovery, matrix effect, specificity, sensitivity, precision and accuracy, carryover and processed sample stability according to the guidelines of the US Food and Drug Administration for bioanalysis. The limits of detection and quantification were 5 and 10 pg/mL, respectively. Linearity was obtained over the concentration range of 10-10,000 pg/mL. To confirm PMA in equine urine, LC retention time, diagnostic product ions (m/z 188, m/z 281 and m/z 323) and product ion ratio were used as the criteria. The lowest concentration for confirmatory analysis was validated at 50 pg/mL. The method was applied to measure the PMA concentrations in equine urine following intravenous administration of fentanyl to a research horse and has confirmed the presence of PMA in post-race urine samples. This method is a valuable addition to the arsenal of equine doping control methods to combat illegal doping and protect racehorse health.

Effects of fentanyl administration in mechanically ventilated patients in the intensive care unit: a systematic review and meta-analysis

BackgroundFentanyl is selected to manage pain in critical care patients on mechanical ventilation in the intensive care unit (ICU). However, the usefulness of fentanyl compared with other opioids is unknown. This study examined the evidence for using fentanyl to improve the clinical outcomes of ICU patients, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.MethodsWe searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi databases in June 2021. Two independent assessors reviewed studies to identify randomized, controlled trials (RCTs) that compared the intravenous administration of fentanyl and other opioids in mechanically ventilated patients in the ICU. The study quality was assessed using the GRADE system and Cochrane methodology. The primary outcome was mortality. The secondary outcomes were the duration of mechanical ventilation, duration of the ICU stay, incidence of severe adverse events, and incidence of delirium. We integrated outcome data using a random-effects model and showed absolute values and certainty of evidence in the GRADE evidence profile.ResultsSeven RCTs met the study inclusion criteria with 534 patients (251 were treated with fentanyl and 283 with other opioids, including 242 with remifentanil and 41 with morphine). Among 191 participants from 2 RCTs, fentanyl was not associated with mortality (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.24 to 2.60; low-quality evidence). Regarding the secondary outcomes, fentanyl did not shorten the duration of mechanical ventilation (mean difference, 0.49 h; 95% CI, − 0.90 to 1.88; moderate-quality evidence) or the duration of the ICU stay (mean difference, 7.04 h; 95% CI, − 3.27 to 17.35; moderate-quality evidence) compared with other opioids. Fentanyl did not increase the incidence of severe adverse events (RR, 0.98; 95% CI, 0.50 to 1.90; low-quality evidence) or delirium (RR, 1.27; 95% CI, 0.79 to 2.04; low-quality evidence).ConclusionsAlthough fentanyl is a frequently administered opioid in the ICU, patients’ outcomes are not different between fentanyl use and use of other opioids. However, the GRADE evaluation provides little certainty to support the results of this systematic review. Therefore, further large RCTs are required to confirm our conclusions.Trial registrationPROSPERO, CRD42019130648 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130648).

Saddle block anesthesia with 20 mg prilocaine hydrochloride 2% hyperbaric solution and intravenous fentanyl administration for transperineal MRI/US fusion-guided prostate biopsy

Introduction: MRI-Ultrasound (MRI/US) fusion-guided transperineal prostate biopsy (TPB) is gaining popularity in the diagnostic algorithm of prostate cancer. It is associated with higher pain score than the other methods of prostate biopsy. Effective analgesia is a key point for providing patient comfort and preventing his movement in response to pain with subsequent mismatch of the fused MRI/ US images. The mismatch could lead to inaccurate targeting of suspected cancer lesions. The preferred method of analgesia in an outpatient setting is topical intrarectal administration of lidocaine and periprostatic nerve block, but the pain and the discomfort from the procedure are not completely eliminated. Hypothetically, saddle block anesthesia has an expected better efficacy in relieving the pain from the MRI/US-TPB. Aim: To evaluate the efficacy and safety of saddle block anesthesia in patients undergoing MRI/US-TPB and сomparative analysis between patients who have received and have not received intravenous fentanyl Material and methods: A prospective randomized study was conducted on 12 consecutive patients undergoing MRI/US-TPB. Saddle block anesthesia was performed with 20 mg prilocaine hydrochloride 2% hyperbaric solution to all patients. 6 patients received intravenous fentanyl at a dose of 1mcg/kg (Group 1) and 6 patients did not receive intravenous fentanyl. It was examined: patient’s age, weight, height, BMI and ASA class; duration from the dural puncture to the end of the surgical intervention; taken number of prostate biopsies; presence of intraoperative pain; motor blockage; presence of a difference of more than 20%, before and after saddle block anesthesia, of non-invasively measured blood pressure and heart rate; additional medication; presence of early postoperative complications and recovery time from anesthesia Results: The comparative analysis of the preoperative characteristics of the both groups did not reveal significant statistical difference. There were comparatively similar indicators for surgical intervention and regional anesthesia in both groups. The both anesthesia techniques showed safety profile with hemodynamic stability, without additional medicine administration and lack of early post-anesthesia complications. Pain did not occur during inserting and moving the US probe into the anal canal and puncturing the perineal skin and the underlying tissues. 50% (3) of the patients in Group 2 had pain during the puncture of the prostate gland and biopsy extraction, while in Group 1 - 0% (0) of the patients reported presence of pain. There was a slightly delayed onset of the first postoperative pain in Group 1 - 113.17 ± 15.11 min. compared to Group 2 - 99.83 ± 11.51 min. Conclusion: The saddle block anesthesia with 20 mg prilocaine hydrochloride 2% hyperbaric solution in combination with intravenous fentanyl at a dose of 1 mcg/kg is a safe anesthesia technique, associated with excellent analgesic profile, low incidence of anesthesia-related complications and rapid recovery in patients undergoing MRI/US-TPB. Key words: saddle block, transperineal MRI/US fusion-guided prostate biopsy, prilocaine hydrochloride 2% hyperbaric solution

A comparison of postoperative pain between transumbilical and suprapubic incision in laparoscopic liver resection.

In laparoscopic liver resection, few reports have investigated the influence of type of incision on postoperative pain in laparoscopic liver resection. We therefore conducted the present study to clarify the difference in postoperative pain between two types of incision. Nineteen patients who underwent laparoscopic lateral sectionectomy were enrolled. In 11 patients with a transumbilical incision and eight with a suprapubic incision, the operation duration, blood loss, length of incision, duration of intravenous fentanyl infusion immediately after surgery and rescue dosage, and period of regular oral nonsteroidal anti-inflammatory drugs were evaluated. There was no significant difference between the two groups in patients' background characteristics, operation time, or amount of blood loss. The length of suprapubic incision was significantly longer than the umbilical incision. Concerning the postoperative pain management, the duration of intravenous fentanyl administration was 1day (1-2 days) for umbilical incisions and 1.5 days (1-2 days) for suprapubic incisions, showing no significant difference. Regarding the rescue dosage of fentanyl, the results were comparable between the groups. Regarding the postoperative duration of regular nonsteroidal anti-inflammatory drug administration, there was also no significant difference between the groups (transumbilical: 14 [5-35] days vs suprapubic: 8 [7-32]). Postoperative pain is comparable between umbilical and suprapubic incision in patients who underwent laparoscopic left lateral segmentectomy. In terms of postoperative pain, either a transumbilical incision or a suprapubic incision can be selected for specimen extraction.

Clinical Pharmacology of Fentanyl in Infants and Children

Fentanyl is a systemic opioid related to the phenylpiperidines, it is used in anaesthetic practice and in analgesia and the analgesic effect is about 100 times higher than that of morphine. Fentanyl is highly lipid soluble, rapidly crosses the blood-brain-barrier, and fentanyl concentrations rapidly decline in plasma and cerebrospinal fluid. Fentanyl causes respiratory depression and decreases the heart rate through vagal activation. Fentanyl may be administered intravenously, orally, by transdermal, intranasal or by buccal application and the oral bioavailability is poor. In infants, fentanyl is given for short term use, sustained use, and during therapeutic hypothermia. In children, fentanyl is given intravenously, by transdermal application, or by buccal administration and the fentanyl dose varies with the child age and body-weight. Fentanyl has been found efficacy and safe in infants and children but it may induce adverse-effects and fentanyl causes different effects in infants and children. Following intravenous administration of fentanyl to infants and children, the fentanyl elimination half-life ranges from 208 to 1,266 min and the distribution volume ranges from 1.92 to 15.2 L/kg. Such variability is due to the wide variation of subject’s demographic characteristics. Fentanyl interacts with drugs, the treatment and trials with fentanyl have been studied in infants and children. Fentanyl freely crosses the human placenta and poorly migrates into the breast-milk. The aim of this study is to review fentanyl dosing, efficacy, safety, effects, adverse-effects, metabolism, pharmacokinetics, drug interaction, treatment, and trials in infants and children, and fentanyl placental transfer and migration into the breast-milk.

Ultrasound-guided femoral nerve block and intravenous fentanyl in pain management of the patients with hip fracture: a prospective, randomized, single blinded clinical trial.

Proximal femoral fracture is a painful condition. Pain alleviation is a treatment cornerstone to both comfort the patient and reduce adverse effects. This study aimed to evaluate and compare ultrasound-guided femoral nerve block and intravenous fentanyl administration in relieving the pain of patients with hip fractures. The present interventional clinical trial was conducted on 40 patients referred to Shahid-Bahonar Hospital with unilateral isolated proximal femur fracture and American Society of Anesthesiologists I and II. The patients were randomly divided into two groups: intravenous fentanyl and ultrasound-guided femoral nerve block for pain management. Pain severity was assessed by a numerical rating scale before and after the intervention in both groups and the groups were then compared. Forty patients were enrolled in to study; 27 (67.5%) were male. There was no significant difference in demographic variables between the two groups. Fourteen (35%) were older than 80 years. Pain significantly decreased three scores compared to the pre-intervention level in both groups (95% confidence interval, 2-4). This was slightly higher in the femoral nerve block group. The largest strength of association for age and numerical rating scale of pain was found in the differences between the pre-intervention and after-intervention in femoral nerve block group (r=-0.775, P < 0.001). We found similar pain severity between the two groups. Considering the possible side effects of fentanyl, an ultrasound-guided femoral nerve block shows may provide safer pain control and may be particularly suitable for patients with opioid dependence.

Comparative Study of Safety and Efficacy of Three Different Doses of Fentanyl on Hemodynamic Response to Laryngoscopy and Tracheal Intubation in Patients under General Anaesthesia

Aim of Study: Laryngoscopy and endotracheal intubation are the commonest method for securing a definitive airway for general anaesthesia. It is one of the most invasive and painful stimuli in anaesthesia producing clinically relevant changes in the hemodynamic variables.&#x0D; This study has been designed to compare the safety and efficacy of three different doses of fentanyl (2µg/kg, 3µg/kg and 4µg/kg) in attenuating hemodynamic response, following laryngoscopy and endotracheal intubation.&#x0D; Materials and Methods: In this observational study, three groups of 90 patients belonging to ASA grade I and II, aged between 18 to 65&#x0D; years, including either gender, posted for elective surgery under GA with informed consent. Baseline vital hemodynamic parameters and the serial heart rate, arterial pressures, SpO2 and respiratory rate were noted at five minutes after intravenous fentanyl administration, during laryngoscopy &amp; intubation and at 1-, 3-, 5-, 10- and 20-minutes after laryngoscopy. Ramsay sedation scores were also noted at five minutes after intravenous fentanyl administration, during extubation and at 10-, 20- and 30-minutes after extubation.&#x0D; Results: There was substantial difference in mean HR, SBP, DBP &amp; MAP values post 5 minutes after intravenous fentanyl administration, during laryngoscopy, at 1, 3-, 5-, 10- and 20-minutes following laryngoscopy and intubation between the three groups. Patients’ behaviour belonging to group C (IV fentanyl 4µg/kg), followed by the patients of group B (IV fentanyl 3µg/kg) presented considerable amount of attenuation of all the hemodynamic stress parameters effectively, with statistically significant results when compared to group A (IV fentanyl 2µg/kg).&#x0D; Conclusion: Intravenous fentanyl 4µg/kg and 3µg/kg are better at attenuating the laryngo-tracheal stress response, in comparison to intravenous fentanyl 2µg/kg.

Low-dose fentanyl does not alter muscle sympathetic nerve activity, blood pressure, or tolerance during progressive central hypovolemia.

Hemorrhage is a leading cause of battlefield and civilian trauma deaths. Several pain medications, including fentanyl, are recommended for use in the prehospital (i.e., field setting) for a hemorrhaging solider. However, it is unknown whether fentanyl impairs arterial blood pressure (BP) regulation, which would compromise hemorrhagic tolerance. Thus, the purpose of this study was to test the hypothesis that an analgesic dose of fentanyl impairs hemorrhagic tolerance in conscious humans. Twenty-eight volunteers (13 females) participated in this double-blinded, randomized, placebo-controlled trial. We conducted a presyncopal limited progressive lower body negative pressure test (LBNP; a validated model to simulate hemorrhage) following intravenous administration of fentanyl (75 µg) or placebo (saline). We quantified tolerance as a cumulative stress index (mmHg·min), which was compared between trials using a paired, two-tailed t test. We also compared muscle sympathetic nerve activity (MSNA; microneurography) and beat-to-beat BP (photoplethysmography) during the LBNP test using a mixed effects model [time (LBNP stage) × trial]. LBNP tolerance was not different between trials (fentanyl: 647 ± 386 vs. placebo: 676 ± 295 mmHg·min, P = 0.61, Cohen's d = 0.08). Increases in MSNA burst frequency (time: P < 0.01, trial: P = 0.29, interaction: P = 0.94) and reductions in mean BP (time: P < 0.01, trial: P = 0.50, interaction: P = 0.16) during LBNP were not different between trials. These data, the first to be obtained in conscious humans, demonstrate that administration of an analgesic dose of fentanyl does not alter MSNA or BP during profound central hypovolemia, nor does it impair tolerance to this simulated hemorrhagic insult.

Effectiveness of Huffing Manoeuvre on Fentanyl Induced Cough

Aim: To determine the effect of huffing manoeuvre to preventing cough caused by intravenous administration of fentanyl during induction of anaesthesia. Study Design: Cross-sectional study Place and duration of study: General Anaesthesia Department, SICU and Pain Management, Civil Hospital Karachi from 1st June 2019 to 30th November 2019. Methodology: One hundred and sixty four patients meeting were enrolled. Every patient was taught to perform huffing manoeuvre by primary investigator visiting patient in ward at night before surgery. The act of huffing manoeuvre was lasts within 5 seconds. Any episode of cough within 60 seconds of fentanyl administration was classified as fentanyl induced cough. All patients were received Propofol (2mg/kg) for induction of anaesthesia. Results: The mean age was 46.42±8.92 years. Incidence of fentanyl induced cough was observed in 4.3% cases and huffing manoeuvre was effective in 95.7% cases. Conclusion: Huffing manoeuvre is an effecting method of reducing fentanyl induced cough in patients undergoing surgery, especially the manoeuvre prevents developing of severe fentanyl induced cough. Keywords: Fentanyl, Cough, Huffing manoeuvre, Analgesic opioids

Trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia (2003-2015).

Fentanyl-related overdose is an ongoing concern among countries with high prescription opioid utilisation. This study examines trends in transdermal fentanyl utilisation and fatal fentanyl overdose across Australia between 2003 and 2015, overall, and by age/sex. This was a retrospective nationwide study of prescription dispensings and coronial records. Transdermal fentanyl utilisation was examined using Pharmaceutical Benefits Scheme dispensing records. Details of fatal fentanyl overdoses were extracted from the National Coronial Information System. Transdermal fentanyl utilisation increased 5.1-fold between 2003 and 2015, from 0.28 to 1.39 mg/1000 population/day and was consistently higher among females and adults aged ≥85 years. The utilisation of higher strength patches (75 and 100 mcg/h) was more common among males aged 25-44 years. A total of 291 fatal fentanyl overdoses were recorded, increasing from no recorded deaths in 2003 to 2.23 deaths/1 000 000 population in 2015. Rates were higher among males (increasing from 0 to 3.72 deaths/1 000 000 population) and for adults aged 25-44 years (increasing from 0 to 5.34 deaths/1 000 000 population). The number of deaths/kg fentanyl dispensed was highest among males aged <25 years (45.45, 95% confidence interval 21.80-83.59). Most deaths (70.1%) involved the intravenous administration of fentanyl from transdermal patches. Rates of transdermal fentanyl utilisation and fatal fentanyl overdose across Australia increased between 2003 and 2015. Although transdermal fentanyl utilisation was consistently greater among females and older adults, rates of fatal fentanyl overdose were highest among younger males. Interventions to reduce extramedical use among this high-risk population group are necessary to minimise fentanyl-related harms.

The Comparison of Postoperative Pain Between Umbilical and Suprapubic Incision in Laparoscopic Liver Resection

Introduction: In laparoscopic hepatectomy, wounds for specimen removal are indispensable. The umbilical incision is commonly used in laparoscopic colectomy and is familiar to gastroenterologists. On the other hand, it has been pointed out that the suprapubic incision method, which is often performed in the gynecological surgery, is superior in terms of postoperative pain, but there is no report comparing the two. Method: From November 2007 to May 2019, 19 patients who underwent laparoscopic lateral segmental resection at our hospital under complete arthroscopy were included. In 11 patients with umbilical incision and 8 patients with suprapubic incision, the operation time, bleeding volume, wound length, duration of continuous intravenous fentanyl infusion immediately after surgery and the number of flushes, and period of regular oral administration of NSAIDs were evaluated. Results: There was no significant difference between the two groups in terms of patient background, age, operation time, and bleeding volume. However, suprapubic incision was significantly longer in wound length than in umbilical incision. Subsequently, for postoperative pain, the duration of continuous intravenous fentanyl administration was 1 day (1-2 days) for umbilical incisions and 1.5 days (1-2 days) for suprapubic incisions, with no significant difference. About the number of fentanyl, the result was comparable. In the period of regular NSAIDs administration, there was also no significant difference with POD14 (POD5-35) in umbilical incisions and POD8 (POD7-32) in suprapubic incisions. Conclusions: In laparoscopic hepatectomy, extirpation of the specimen by umbilical incision is acceptable.

Comparison of low dose intravenous fentanyl and morphine infusion for postoperative analgesia in spine fusion surgeries – a randomized control trial

Background and aimsPost-operative analgesia for Spine surgeries is difficult without patient control analgesia (PCA) and inadequate monitoring facilities. The objective was to study the effectiveness of analgesia of intravenous administration of low dose fentanyl and morphine for postoperative analgesia following spine fusion surgeries. MethodsOne hundred adult patients undergoing spine instrumentation surgeries were randomly allotted into two groups: Group M (morphine) or Group F (fentanyl). The patients received either 0.02 mg.kg-1.h-1 of morphine or 0.3 mcg.kg-1.h-1 of fentanyl infusion postoperatively. If the patient had pain, additional bolus dose of 0.04 mg.kg-1 and 0.6 mcg. kg-1 bolus for morphine and fentanyl respectively were given and noted. The additional analgesic consumption was recorded. The Ramsay sedation score (RSS), visual analogue score (VAS), vital parameters and complications were observed. ResultsThe demographic characteristics did not reveal significant difference among the two groups. In morphine group, 32 patients did not require any additional bolus dose, 15 patients needed one bolus dose and one patient each required two and three boluses. In fentanyl group, two, 24, 20 and four patients required 0, 1, 2 and 3 bolus doses respectively. There were no statistically significant variations in hemodynamic features like heart rate, blood pressure and oxygen saturation, RSS and VAS. The complication rate was not significant among the groups. ConclusionLow dose continuous infusion of morphine is more effective than fentanyl with fewer requirements of rescue analgesics for postoperative analgesia. Both drugs are safe without any serious complications.

Безопіатна аналгоседація під час стентування коронарних артерій

The widespread usage of opioids / opiates in anesthetic practice has highlighted a number of related problems. Therefore, in recent years, the concept of opiate-free anesthesia has been gaining popularity among anesthesiologists around the world. In this context, we are interested in lidocaine as a component of this anesthesia. The attention of anesthesiologists to lidocaine during analgesia is due to its analgesic, anti-inflammatory and antihyperalgesic properties. The basis of the analgesic effect of the drug is that it blocks sodium channels and depolarizes nociceptive peripheral neurons, simultaneously inhibits NMDA receptors, reduces the number of cytokine complexes circulating in the plasma, and dissociates the Gq protein. In general, these properties lead to a decrease in opiate consumption, an acceleration of rehabilitation, a decrease in episodes of nausea and vomiting, a reduction in hospital stay, and even has certain neuroprotective properties. The purpose of our work was to establish the main aspects of non-opiate anesthesia usage that was based on lidocaine during coronary stenting. Material and methods. We studied 60 patients with coronary artery disease who underwent stenting of the coronary arteries in a planned manner. The main diagnosis was exertional angina FC II-III. In terms of the duration of the surgery, it was 38.54±19.3 minutes, and the number of stents was 1.3±0.7. The patients were evenly divided into two study groups, depending on the prescribed drug regimen. The first group included patients who were sedated by slow intravenous administration of diazepam and fentanyl. In the group of non-opiate anesthesia, a lidocaine solution was the main component of analgesia. At the stages before the start of the surgery, during the main stage, namely, the stent placement, and after the end of the surgery, the parameters of hemodynamics, saturation, gas and electrolyte composition of blood, the level of glycemia and cortisol were assessed. Results and discussion. The main complaint of patients in the control group was drowsiness, which was noted by 36.7% of patients. We attribute this feature to the use of diazepam. However, drowsiness was also noted in 33.3% of the experimental group after surgery. This fact can be explained by the use of significant doses of propofol, which were needed to maintain hemodynamics at the appropriate level. Episodes of nausea and vomiting may occur during surgery, especially when using opiates with a high probability. The phenomena of nausea were observed in 13.4% of the 1st group, and in the 2nd group it occurred in 3.3% of cases. According to the recommendations, we administered 4 mg of ondasetron solution after which the nausea disappeared. In the second group, complaints related to the local anesthetic effects of lidocaine came to the fore. 63.3% complained of "crawling ants" or numbness in the hand, the same sensations in the cheek and numbness of the tongue – 33.3%. After the operation, the feeling of numbness in the hand persisted in 16.7%. It should be noted that these sensations did not cause significant discomfort and did not interfere with anesthesia. Conclusion. In the course of the work, we came to the conclusion that the usage of lidocaine at a dose of 1 mg / kg of the patient's body weight is safe for coronary artery stenting operations and, at the same time, there are no negative effects inherent in opiate based anesthesia. At the same time, the local anesthetic effects after using lidocaine do not worsen the course of the postoperative period

176. Thoracolumbar interfascial plane (TLIP) block and intrathecal fentanyl injection results in an opioid-free peri- and postoperative recovery and early ambulation after percutaneous lumbar spine surgery

BACKGROUND CONTEXT Open lumbar spine fusion surgery usually requires opioid analgesia for several weeks during the postoperative recovery period. Recently, a facet-sparing, full percutaneous transforaminal lumbar interbody fusion (TLIF) has been introduced that uses an endoscopic cannula for placement of an interbody cage in combination with percutaneous transpedicular screws and rods. The Thoraco-Lumbar Interfascial Plain (TLIP) block is a novel, ultrasound-guided local anesthesia technique that targets the sensory component of the dorsal rami of the thoracolumbar nerves. PURPOSE We aim to evaluate the efficacy in avoiding post-operative opioid analgesics and allowing early patient ambulation of a novel inter-disciplinary, spine surgery protocol that combines a perioperative TLIP block, intrathecal fentanyl injection and percutaneous TLIF spine surgery. STUDY DESIGN/SETTING Prospective, nonrandomized sequential case series study. PATIENT SAMPLE A total of 15 consecutive patients underwent TLIP combined with percutaneous TLIF spine surgery between 2018 and 2019. Indication for spine surgery was degenerative disk disease of the lumbar spine with or without spondylolisthesis up to grade 2 and foraminal stenosis. OUTCOME MEASURES Pre- and postoperative visual analogic scale (VAS) for lumbar back and leg pain were quantitatively assessed (range 0 to 10) immediately, at 6 and at 12 hours after surgery and at time of hospital discharge. Oswestry Disability Index (ODI) scores (range 0 to 50) were assessed preoperatively and at time of hospital discharge. The time of first post-operative patient ambulation was registered. Significance between pre- and postoperative scores were analyzed with student's paired t-test. METHODS Intrathecal fentanyl 25 mcgr was administered to the patient in sitting position and ultrasound-guided bilateral TLIP was performed in prone position with bupivacaine 0.25% and dexamethasone 8mgrs (20ml each side) by the anesthesia team. All patients were operated on under general anesthesia (protocol: propofol 2.0-3.0 mcg/ml (TCI) following BIS, ketamine 0.15 mg/Kg/h, rocuronium 0.4 mg/Kg). Percutaneous TLIF was performed by inserting an expandable interbody implant using the facet-sparing, trans-Kambin approach with an endoscopic cannula and complemented with a percutaneous posterior fixation consisting of transpedicular screws and rods. Postoperative analgesia included NSAIDs, acetaminophen and a manually patient-controlled oral sublingual 15 mcgr sufentanil microtablet analgesic system (Zalviso®), while its use was monitored. RESULTS Fifteen patients with a mean age of 64.1 years (range, 34 to 82 years) were evaluated. A median of two levels (range, 1 to 4 levels) per patient were instrumented and a median of one interbody cage (range, 1 to 2 cages) was placed in the lumbar spine. No intravenous fentanyl administration was necessary during surgery. The median time of surgery was 3.5 hours. Mean preoperative VAS scores for lumbar back and leg pain were 6.3 and 5.8, respectively. Mean postoperative VAS back scores at 0h, 6h, 12h and at discharge improved to 1.2, 1.8, 2.4 and 2.7 (P CONCLUSIONS The combination of perioperative TLIP, intrathecal fentanyl injection and percutaneous TLIF surgery prevents peri- and postoperative opioid administration and improves the quality of peri- and postoperative analgesia, allowing early patient ambulation and fast hospital discharge. This interdisciplinary analgesia protocol is a promising solution to avoid opioid analgesia in spine surgery and could be particularly interesting in the context of an outpatient spine surgery setting. FDA DEVICE/DRUG STATUS Fentanyl (Approved for this indication), Zalviso (Approved for this indication), Bupivacaine (Approved for this indication), Globus RISE (Approved for this indication)

Comparing the different oxycodone doses of prevent oxycodone for prevention of preventing fentanyl-induced cough during induction of general anaesthesia.

Fentanyl-induced cough (FIC) usually occurs after the intravenous administration of fentanyl duringgeneral anaesthesia induction. It is a transient condition depending on the fentanyl administration dose and injection speed. Oxycodone can also prevent FIC because it has been proven to treat coughing. This study aimed to evaluate the efficacy of different oxycodone doses to prevent FIC during general anaesthesia induction. In a double-blind randomised controlled trial, 210 adult patients who were undergoing elective surgery, classified as American Society of Anaesthesiologists physical status I-II, and aged 20-65years were randomly assigned into five equally sized groups: Sham group, Group Ⅰ, Group II, Group III and Group IV. Groups Ⅰ-IV were each intravenously injected with oxycodone 0.025, 0.05, 0.075 and 0.100mg/kg, while an equal volume of normal saline was given instead of oxycodone in the Sham group. Five minutes later, fentanyl 3μg/kg was intravenously injected within 5seconds, then, 2minutes later the other drugs were administered for generalanaesthesia induction. The occurrence and severity of coughing were observed within 2minutes of the fentanyl injection. Vital signs and intensities of coughing were recorded and analysed. Coughing incidences were each 57.1, 50, 42.8, 33.3 and 21.4% in the Sham group and Groups Ⅰ-IV. Significant differences were found in the incidences of coughing between the Sham group and Groups III-IV. No significant differences in FIC incidences have been detected between the Sham group and Groups Ⅰ-II. However, no significant difference in FIC incidence existed between Group III and Group IV. Cough severities in Groups III and IV were significantly lower than in Groups Ⅰ and II (P<.05). No significant differences existed in the hypotension or severe bradycardia incidences during anaesthesia induction among the five groups (P>.05). Oxycodone 0.075mg/kg provided more effective FIC prevention during general anaesthesia induction.

Postmortem Brain-Blood Ratios of Codeine, Fentanyl, Oxycodone and Tramadol.

The analgesics, codeine, fentanyl, oxycodone and tramadol, frequently occur in postmortem cases and determining their role in the cause of death can be challenging. However, postmortem blood is susceptible to redistribution and may not be available in cases of severe blood loss, putrefaction or burns. Brain tissue may serve as a viable supplement to blood or on its own, as it is resistant to postmortem redistribution and often available as a sample matrix when blood is not available. We present brain and blood concentrations and brain-blood ratios of the four analgesics from 210 autopsy cases. The cases were classified according to the presumed cause of death: A: The compound was believed to have solely caused a fatal intoxication. B: The compound was assumed to have contributed to a fatal outcome in combination with other drugs, alcohol or disease. C: The compound was not regarded as being related to the cause of death. Blood and brain samples were prepared by automatic solid phase extraction and quantified by liquid chromatography-mass spectrometry. The squared correlation coefficients between concentrations in brain tissue and blood ranged 0.45-0.91. The median brain-blood ratios were codeine 1.8 (range 0.47-4.6), fentanyl 2.1 (range 0.29-16), oxycodone 1.8 (range 0.11-6.0) and tramadol 1.8 (range 0.047-6.8). A significantly higher brain-blood ratio of codeine was observed in cases where heroin had been administered, although there was a wide overlap. Intravenous and transdermal fentanyl administration could not be distinguished based on the blood or brain concentration or the brain-blood ratio. The results of this study may benefit the toxicological investigation in postmortem cases where one of the four analgesics are suspected of having contributed to or caused a fatal intoxication.

Desflurane is not inferior to sevoflurane in the occurrence of adverse respiratory events during laryngeal mask airway anesthesia: a non-inferiority randomized double-blinded controlled study.

Compared to sevoflurane, desflurane is less favorable to most anesthesiologists for laryngeal mask airway (LMA) anesthesia because desflurane has a pungent odor. This non-inferiority study aimed to determine whether desflurane is not worse than sevoflurane in triggering airway irritations during general anesthesia using LMA. Patients scheduled for elective surgery under LMA anesthesia were randomly allocated to receive either desflurane or sevoflurane for maintenance of anesthesia. After intravenous fentanyl, lidocaine and propofol administration followed by LMA insertion, 0.5-1.0 MAC of the volatile anesthetic in 50% N2O was maintained throughout the surgery. The primary outcome was the occurrence of perioperative adverse respiratory events. Other outcomes included recovery profiles, hemodynamic changes and postoperative complications. One-hundred and ten patients per group completed the study without any serious complications, lost to follow-up, or protocol deviation. During awake LMA removal, patients in the desflurane group experienced lesser episodes of laryngospasm (risk difference, -7.3%; 95% CI, -12.7% to -1.9%; P=0.009) than those in the sevoflurane group. The emergence time and time to LMA removal were significantly shorter in the desflurane group. The quality of recovery indicated by an ability to self-transfer from bed to bed was significantly better after desflurane anesthesia. No difference between groups was found in a return of orientation and a readiness for post-anesthesia care unit discharge. Desflurane is non-inferior to sevoflurane in the occurrence of laryngospasm at emergence after LMA anesthesia. The superiority of desflurane compared to sevoflurane with regards to respiratory complications requires further investigation.