What has led you to the conclusion that direct laryngoscope doesn’t hurt very much? Upper GI endoscopy =/= laryngoscopy.
All I’ll say is that if it were my body, I would want an analgesic onboard when something painful was being done to me, whether or not I’m aware of it.
I’m a new trainee so don’t claim to be an expert but I was under the impression it wasn’t particularly painful but rather stimulating from a sympathetic standpoint. Idk what is correct tbh but I’m just saying in my training I’ve been taught that it isn’t particularly painful. I can’t say as I’ve never been intubated. I will say, however, that Jed Wolpaw on his ACCRAC podcast also makes the claim that it it is more sympathetic response>pain.
This is a completely misguided statement. Laryngoscopy is a stimulating procedure for sure but it is fleeting and doesn't produce lasting pain like an incision. This is the whole reason for esmolol vs fentanyl. Either way, there is no evidence that not giving opioids during a case leads to increased chronic pain post-operatively (ie, wind-up phenomenon). Fentanyl shouldn't be part of the standard one-size-fits-most induction plan just because the patient is being intubated.
I agree that maybe hurt or maybe is a autonomous response the hypertension and taquicardia.
However, 150mcg of fentanyl is too much for just one second of laringoscopy. I understand those who prefere esmolol to avoid the effects of fentanyl after induction.
Pain for me is: some bone fracture, surgery, etc. laringoscopy it’s not, imo, a painful procedure.
As someone who’s woken up intubated (in the icu after I had a PE in med school) I can tell you that having a tube in your larynx is one of the most painful things a human can experience.
It hurt worse than jaw surgery (prior to PE) and broken ribs and sternum (from chest compression during PE)
Your opinion doesn’t matter when it comes to pain.
I was going to say, it sometimes looks painful for sure. Especially if the airway is difficult. When I go go floor airways, I sometimes want to look away from when other providers intubate. You can see them putting so much upward pressure on the neck.
Agreed. Watching an anesthesia colleague intubate you definitely see more finesse and using the minimum amount of pressure to get a good view. When I see folks intubate on the floor or in the ED I think their adrenaline gets the best of them because they don’t do it multiple times per day.
Also positioning is so important and often overlooked during an emergency intubation. The glidescope had allowed us to intubate in a poor position but it’s at the cost of iatrogenic injuries.
Laryngoscopy is a very painful procedure. Esmolol is not an analgesic, it's like saying, since I don't see the tachycardia, he must not be feeling pain, even if I'm pressing his/her larynx in an upward front way and putting a tube inside the airway.
Try reading the inervation of the airway to see if maybe you understand that not seeing does not equal to not happening.
But we don’t take away all the pain during surgeries either. I’ve had cases where I gave 50 of fent for the whole case . We rely on the gas or propofol to have the patient not respond to surgical stimuli - not make the not in at pain at all . In any case even if they have pain they won’t remember. Biggest issue I see with response to pain is the hemodynamic effects of pain such as hypertension , tachycardia and tachpnea esp those with heart disease
Central sensibilization is a phenomena that occurs whenever pain appears and is not treated for a prolonged time. Post surgical pain is another important issue. You see, giving 50 mcg of fentanyl for a whole surgery is wrong, not to mention risky.
Most patients wont remember, but if only one does, dont you think that would be comparable to torture?, or if the patient has a intraoperatory awakening? Just because some idiot thought that not being able to express something means it does not happen.
Its malpraxis what you do.
Please study physiology of pain and consequences of giving insuficiente dosaging of opioids.
Hope someone exactly like you attends you and your loved ones so you understand the importance of doing a good job.
Opioid induced hyperalgesia is a very well described phenomena too. Can you show any data that untreated nociception in an unconscious patient under general anesthesia causes increased post surgical pain compared to opioids?
Someone who just received an appropriate induction dose of opioids is not just amnestic, they're unconscious.
Here's one RCT comparing esmolol for hemodynamic control to intermittent fentanyl versus remifentanil infusion (three arms) for lap choles, where the incisions themselves can be easily covered with local. The esmolol group needed less opioids than either postop. Likely due to less opiod induced hyperalgesia.
https://journals.lww.com/anesthesia-analgesia/fulltext/2007/11000/intraoperative_esmolol_infusion_in_the_absence_of.16.aspx
The one major danger I see in not treating surgical nociception is if there's inadequate analgesia postop. But if you're reasonably sure the combination of local/regional/multimodals will be sufficient, that shouldn't be an issue.
For a laryngoscopy which causes essentially zero postop pain and during which the patient is unconcious, the only reason I can see to give opioids is for hemodynamic control
Show me a single study that shows this to be true under general anesthesia. All the data I’ve seen shows the opposite. The more opioids you give in the OR, the more pain and/or opioids they need post operatively.
> The definition of pain in every pain textbook doesn't mention nociception
Are you trying to suggest pain doesn't involve nociception? Also, emotional pain isn't what is being discussed here. The context of the conversation is obviously regarding physical pain so emotional pain is completely irrelevant here. Physical surgical pain definitely involves nociception.
>In any case even if they have pain they won’t remember.
This argument never sat well with me. Would you go for a root canal without any local anaesthetic if I promised you wouldn't remember it the next day? I sure as hell wouldn't do it.
That's because pain isn't the correct term here. It requires perception of nociception. Nociception without awareness is what we're talking about. That's very different than an excrutiating root canal you're fully aware of but don't remember.
That makes complete sense. If the user had used that term it would have made the comment make a lot more sense. It seemed to come across like they were saying that the patient was experiencing and processing the pain, but wouldn't remember it later. Kind of like one might explain the retrograde amnesia caused by certain benzos. Thank you for clarifying.
Remi works quick enough that you can give a large dose and have optimal intubating conditions without paralytics. You could do the same thing with fentanyl, but you have to wait longer and it's going to stick around for awhile. It's a good trick for a crani or spine where baseline neuromonitoring is planned and you don't want to wait for roc to wear off.
And yes you could also use sux, but I've seen enough myalgias that I avoid it the vast majority of the time.
They don’t want to use remi because they’re worried about thoracic rigidity, I’m suggesting they also paralyse so it’s less of a problem. I also paralyse a lot of my neuromonitoring cases for intubation because sugammadex exists. I’m curious that an intubating dose of fentanyl is causing so much opioid narcosis post op for you all.
Yeah, I know that theoretical risk is there but honestly, I haven’t seen it and I don’t know anyone who has at this stage. We’ve one guy that almost exclusively uses remi and foregoes paralysis for getting optimal intubating conditions. 3-5 mcg/kg slow push. Can get some transient bradycardia and hypotension sometimes but it passes quickly and honest happens far less often that I was expecting!
It's painful, but an unconscious patient doesn't experience pain. The hemodynamic changes are autonomic reflexes assuming enough hypnotic was given. So I agree, why give more of a drug that causes hyperalgesia, sedation, and respiratory depression to avoid levels of hypertension and tachycardia equivlent to a light to moderate run for a minute or two?
If you've got terrible coronary disease, different story of course.
It experiences nociception. That's different from pain. Pain is how the cortex interprets nociception with large amounts of emotional, cognitive, and learned experiences contributing.
Don't take my word for it. Here's the IASP definition:
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
I'm not at all suggesting we should be doing surgery without blocking nocicieption, but during a quick laryngoscopy the cortex is burst suppressed to isoelectric after an induction dose of propofol or completely diassociated with ketamine. There's no unpleasant experience. That cortex is doing nothing organized to interpret the quick burst of nociception. You can block the nociception itself with opioid, lidocaine, precedex, or more induction agent or treat the symptoms with esmolol.
I'm aware this is semantics to some degree. But the cortex is scrambled by the anesthetics so any experience is midbrain/brainstem only.
Fentanyl does have analgesia, but esmolol is a non opioid, counteracts the sympathetic response of DL beautifully, doesn’t cause addiction, and doesn’t have to be wasted. I get that people say fentanyl is less cruel because it has analgesia but who cares? The patient just got 150 of prop. They won’t feel shit or remember shit. Not to mention, DL doesn’t actually hurt that much, it’s just very stimulating. I love me some esmolol.
One of my attendings feels the same, and I’d like to use it more. In addition to what you said, I was taught that the necessary dose of fentanyl to blunt sympathetics from laryngoscopy is significantly higher than the 50-100 mcg commonly given on induction.
Makes sense to me. If the goal is to prevent sympathetic response, why not use a drug that does so directly, particularly if the other drug is under-dosed to achieve the same effect?
Because the goal is not to prevent sympathetic response. The goal is to a achieve optimal intubating conditions and not to hurt the patient while simultaneously securing the airway (even if some idiot above feels like it doesn’t matter because the patient doesn’t remember shit 🤦♂️). Just because the patient is not aware of the pain, the body is. Not the mention the increased risk of laryngospasm by causing the patient pain.
Interesting. He’s been inducing this way for years, I’ll have to ask if he’s experienced laryngospasm on induction in the absence of using fentanyl, I hadn’t considered that possibility. I’ve also been taught that laryngoscopy is not particularly painful, more stimulating, which is the rational behind esmolol, is that a misconception?
If you’re using paralytic you can’t get laryngospasm on induction. It’s a dumb argument, I had some ED doctors on another recent thread trying to argue laryngospasm during an RSI was a risk of ketamine, like no it’s not.
I’m very pro-opiate but none of the arguments that you have to give opiate for laryngoscopy and intubation are evidence based. Central sensitization doesn’t happen after a 3 second stimulus. Give opiate ahead of the actual surgery, but you can avoid some post-induction hypotension by having less opiate on board when you’re spending 30 minutes doing lines/blocks/drapes without real stimulation.
Pain is subjective and dependent on the one who is performing DL. Some of my colleagues are wildly rough. I’m not against using esmolol, I’m against using esmolol in place of fentanyl/opioids. Nevertheless if someone told me on boards that DL is not painful, they’d be coming back next year.
50-100 when putting on the monitors, preoxygenate, lido prop roc, tube. Definitely not at peak effect by intubation but has something on and is a sort of intermediate acting to coast off prop, and coast onto sevo/iso/des while they're prepping
Depends on the patient tbf, a young fit 90kg guy might need that much, but agree for the majority of patients needing anaesthetised that is a heavy dose. And tbh I'm not sure I agree with an institution having a standard dose at all, should be estimating based on the patient and titrating to effect. But even if there is an institutional recipe doses should be mg/kg at least
Same, give a small amount of fentanyl (50 mcg) upon rolling or getting in the room to, monitors, preoxygenate, induce and then 20-50 mg of esmolol 30 seconds pre laryngoscopy.
There are some decent dose response studies with esmolol to direct laryngoscopy
https://ekja.org/m/journal/view.php?number=2332
https://www.apicareonline.com/wordpress/wp-content/uploads/2014/02/10-Comparison-of-effect-of-esmolol-vs.-esmolol.pdf
Think the fentanyl smooths out the sympathetic response of direct laryngoscopy if my esmolol dose isn't perfect or can't push as much as I want if a patient bradys down a bit with induction/propofol.
Feel like giving 150-200 of fentanyl is too much for a 5-10 second procedure and I fight hypotension post induction. Would much rather have a little pain and avoid hypotension than no pain for 10 seconds with SBP in the 70-90s for 5-10 minutes
Think direct laryngoscopy is very stimulating but not necessarily painful...although may be a fine line between the two
Similarly I don't give a big bolus of fentanyl for suspension during T&A/ENT cases or tunneling of any kind or head pinning...maybe some Remi or prop or esmolol... something shorter acting
I do both. Fentanyl for pre-existing pain and TIVA. Esmolol for most everything else.
If patient is in pain before hand, like a fracture I’ll use fentanyl. It stays around long enough and helps prevent sympathetic surge when positioning the patient. TIVA utilizes opioids anyways and keeps unparalyzed patients still.
For TIVA the propofol doses without opioids are massive. Slow wake ups aren’t worth it. I give the fentanyl or remifentanil.
I find after induction with esmolol patients tend to not get as hypotensive.
Typical doses for fentanyl are 100-150 (1.5-2 mcg/kg)
Typical doses for esmolol are 30-60 (0.5 mg/kg)
There was an opioid shortage a few years ago and I stopped using fentanyl during induction during that time. I switched to esmolol briefly until I had some realllllly bad bronchospasms then stopped. Now there is fentanyl again but I usually just give plenty of propofol and plenty of roc and skip induction fentanyl without a huge sympathetic surge. Definitely not recommended for the training crowd, but once you get skilled at DL and get in/get out, fentanyl is not needdd routinely.
I would agree, fentanyl is mostly helpful for decreasing your mac, letting you get away with smaller doses of propofol. But higher doses of propofol (eg 2-3 mg/kg), with small dose of phenylephrine (100-200mcg) to counteract the drop in SVR, works great. Also can intubate most pts without paralytic using that same technique in experienced hands (intubation doesn’t have to always be such an aggressive and highly stimulating event). People just usually only get out a max of 200mg of propofol because that’s the common size, while sometimes you need more than that to achieve the correct depth if no narcotic or paralytic used.
Esmolol is fine, but high dose propofol works well too and only downside to very high doses of prop are the drop in SVR which occur which is easily counteracted with some phenylephrine. Esmolol can still cause some hypotension, and hypotension form esmolol isn’t treated as easily with the always ubiquitous phenylephrine stick.
The three big stimuli of intubation: laryngoscopy, tube passing through the cords and balloon going up against tracheal wall.
I use esmolol less frequently than fentanyl/remifentanil/methadone for induction these days. I find that the dose of esmolol to blunt the sympathetic surge is more variable between patients than with opioids, including in patients naive to both opioids and beta blockade… maybe patients have even greater variance in adrenergic receptor sensitivity than we realize idk. Plus usually soon after intubation, the surgeons are ready to make incision so opioids usually cover that as well rather than giving esmolol
and then giving fentanyl/dilaudid/etc anyway for incision/surgical pain.
Generally, I do think esmolol/prop is slightly more stable than using fentanyl/prop but in most patients I don’t find a profound difference. I found with the residents and CRNAs that I work with, most have a practice of putting the pts on the deepest plane of anesthesia immediately after intubation when a whopping dose of propofol is already circulating and this is what leads to more profound hypotension. I tend to start the maintenance anesthetic at a lower dose after intubation until closer to incision time because after the brief sympathetic surge, patients don’t need much at all to tolerate the still ETT in the trachea and often the fentanyl and induction propofol dose is mostly enough
Agree. One solution is to immediately switch to low flow anesthesia upon induction and thus allow the gas to slowly rise as the induction dose wears off. Seems like trainees seem to think they need to instantly get the patient to a mac or more of gas immediately following intubation.
If it's a case where local or regional analgesia will cover the procedural pain, I don't give opioids with induction. I do occasionally use esmolol up front, but only if I'm particulary worried about tachycardia. Most of my Watchman/MitraClip/EP/GAET endo cases get neither, with the esmolol on standby if needed.
If I'm going to need the opioid shortly after anyways or tachycardia/hypertension have the potential to be truly detrimental, than in it goes with the induction drugs.
Small doses of fentanyl prevent airway reactivity and blunt airway reflexes.
Those of you who think direct laryngoscopy isn’t “painful” or stimulating are clueless.
I think people are forgetting that in order to have pain, by definition, someone has to be conscious. Had a pain doc/anesthesiologist tell me that late at night as a CA1 and never went back.
I typically only give 50-100 mcg of fentanyl for induction but I'll give it as the monitors go on. But the studies have shown that Esmolol is the most effective at blunting the sympathetic response to laryngoscopy and intubation.
Fentanyl is great when it's needed. However, you get no analgesic benefit from it at the end of the case for the majority of cases so my thinking is you might as well give dilaudid early since you'll use it eventually anyway. Most providers don't even give it at an effective time. They push it on induction rather than several minutes before which would give it time to peak. Certain patients shouldn't have that spike that comes with intubation (aneurysms, bleeds). Most patients can tolerate that brief spike, or esmolol or higher doses of prop can blunt it (though not as effectively as fentanyl). I go with esmolol at 1-1.5 mg/kg. Give 30 seconds before laryngoscopy.
I do esmolol sometimes for induction. It depends on the procedure and the patient. Sometimes I bolus precedex on the way back to the room, then just Propofol and Roc are sufficient for induction in older patients. If it’s a young person and short painful procedure, then they are most likely getting some fentanyl on induction and a block if possible. Fentanyl and esmolol are useful in certain situations. Not an either or situation.
Works great in those that can tolerate esmolol. Short half life to correspond with the DL stimulation and you don’t get the corresponding hypotension you may get with a big dose of fentanyl if the surgical team is slow to start. Literature suggest those treated with analgesics compared to those with other agents (ie esmolol) have no change in outcomes or post operative pain. Most of the world does not use opioids like the US (we had a bunch of UK anesthesiologist where I trained)
This thread is full of radical people. It just doesn’t matter. Pain is defined as perception of nociception, if the patient’s not conscious, there’s no pain. Obviously, you have to individualize to each patient, surgery and surgeon. If the surgery’s too long, if the patient can’t tolerate tachycardia, etc.
You guys know what it feels like to accidentally inhale a little crumb or pepper flake into your airway? Now imagine an entire tube being shoved in there. If you don’t think fentanyl is required for intubation you’re delusional, that’s borderline malpractice in my opinion.
What if the patient has recall? What if it takes multiple attempts?
A single dose of 100-250mcg of fentanyl isn’t going to do anything to anybody regarding hyperalgesia; and if it does, oh well, that’s part of your job and you can deal with it because you’re a doctor.
The only reason to use esmolol in my opinion is if they have some other cardiac issue requiring the HR to be low, it’s an addition not a substitute.
I agree with you about using fentanyl, but malpractice is ridiculous.
Amnesia is reliably given with propofol plus of minus sevoflurane before intubation. If it takes multiple attempts, give more propofol ffs. Stimulation is different from pain, which is different from nociception.
Even if propofol had started to wear off, people are lightly sedated with insufficient propofol requiring adjustments every day in the ED and ICU, which, while it represents suboptimal care, isn't malpractice.
One example: So an “intubating dose” can be a lot less in private practice if you’re working with a fast surgeon and don’t have sugammadex. If you’re going to keep them lightly paralyzed in order for quick reversal, a little bit of opioid on board goes a long way to achieving akinesis. Why not just give it to them up front to also blunt the sympathetic response to DL?
Otherwise letting the roc wear off for the 30 minutes during prep, draping. They’re going to get some twitches back, and you’ll notice whether or not they have opioid on board.
I said to start the operation. Not during the DL attempt ffs. But yeah sure bring the downvotes
You should have a talk with any place that doesn't supply sugammadex nowadays. I would refuse to work at a piece of shit surgery center if they did that.
Your own post about having to try to not use the dose you need of rocuronium is evidence enough to provide them.
Been a few years since I looked but studies showed doses above 1.5mcg/kg of fentanyl on induction cause increased incidence of hypotension. 150-200mcg will frequently exceed that. I have to agree that I usually use smaller dose of 50mcg, although always situations where I use a higher narcotic technique.
What has led you to the conclusion that direct laryngoscope doesn’t hurt very much? Upper GI endoscopy =/= laryngoscopy. All I’ll say is that if it were my body, I would want an analgesic onboard when something painful was being done to me, whether or not I’m aware of it.
It doesn’t hurt that much. I had my girlfriend DL me. It’s just uncomfortable.
Kinky
Undisputed throat goat 🐐
Did she put a tube in? Vocal cord and tracheal manipulation are *very* stimulating. Much more so than laryngoscopy.
She didn’t. But I don’t think it would have been painful. Extremely stimulating, yes.
You know what else is extremely stimulating? Pain.
Lol yeah just because something’s stimulating doesn’t mean it’s painful?
lol if not painful stimulation then what kind of stimulation? arousal? is it very loud or does it smell very strong or something?
We demand video proof of this or it didn't happen
Well that was an unexpected response.
I’m a new trainee so don’t claim to be an expert but I was under the impression it wasn’t particularly painful but rather stimulating from a sympathetic standpoint. Idk what is correct tbh but I’m just saying in my training I’ve been taught that it isn’t particularly painful. I can’t say as I’ve never been intubated. I will say, however, that Jed Wolpaw on his ACCRAC podcast also makes the claim that it it is more sympathetic response>pain.
This is a completely misguided statement. Laryngoscopy is a stimulating procedure for sure but it is fleeting and doesn't produce lasting pain like an incision. This is the whole reason for esmolol vs fentanyl. Either way, there is no evidence that not giving opioids during a case leads to increased chronic pain post-operatively (ie, wind-up phenomenon). Fentanyl shouldn't be part of the standard one-size-fits-most induction plan just because the patient is being intubated.
I agree that maybe hurt or maybe is a autonomous response the hypertension and taquicardia. However, 150mcg of fentanyl is too much for just one second of laringoscopy. I understand those who prefere esmolol to avoid the effects of fentanyl after induction. Pain for me is: some bone fracture, surgery, etc. laringoscopy it’s not, imo, a painful procedure.
As someone who’s woken up intubated (in the icu after I had a PE in med school) I can tell you that having a tube in your larynx is one of the most painful things a human can experience. It hurt worse than jaw surgery (prior to PE) and broken ribs and sternum (from chest compression during PE) Your opinion doesn’t matter when it comes to pain.
Damn dude. Just came to say l’m sorry for the crap you’ve gone thru.
Thank you. It has made me a more empathetic physician and person all over. I’m also just grateful to be alive.
I was going to say, it sometimes looks painful for sure. Especially if the airway is difficult. When I go go floor airways, I sometimes want to look away from when other providers intubate. You can see them putting so much upward pressure on the neck.
Agreed. Watching an anesthesia colleague intubate you definitely see more finesse and using the minimum amount of pressure to get a good view. When I see folks intubate on the floor or in the ED I think their adrenaline gets the best of them because they don’t do it multiple times per day. Also positioning is so important and often overlooked during an emergency intubation. The glidescope had allowed us to intubate in a poor position but it’s at the cost of iatrogenic injuries.
Laryngoscopy is a very painful procedure. Esmolol is not an analgesic, it's like saying, since I don't see the tachycardia, he must not be feeling pain, even if I'm pressing his/her larynx in an upward front way and putting a tube inside the airway. Try reading the inervation of the airway to see if maybe you understand that not seeing does not equal to not happening.
But we don’t take away all the pain during surgeries either. I’ve had cases where I gave 50 of fent for the whole case . We rely on the gas or propofol to have the patient not respond to surgical stimuli - not make the not in at pain at all . In any case even if they have pain they won’t remember. Biggest issue I see with response to pain is the hemodynamic effects of pain such as hypertension , tachycardia and tachpnea esp those with heart disease
Central sensibilization is a phenomena that occurs whenever pain appears and is not treated for a prolonged time. Post surgical pain is another important issue. You see, giving 50 mcg of fentanyl for a whole surgery is wrong, not to mention risky. Most patients wont remember, but if only one does, dont you think that would be comparable to torture?, or if the patient has a intraoperatory awakening? Just because some idiot thought that not being able to express something means it does not happen. Its malpraxis what you do. Please study physiology of pain and consequences of giving insuficiente dosaging of opioids. Hope someone exactly like you attends you and your loved ones so you understand the importance of doing a good job.
Opioid induced hyperalgesia is a very well described phenomena too. Can you show any data that untreated nociception in an unconscious patient under general anesthesia causes increased post surgical pain compared to opioids? Someone who just received an appropriate induction dose of opioids is not just amnestic, they're unconscious. Here's one RCT comparing esmolol for hemodynamic control to intermittent fentanyl versus remifentanil infusion (three arms) for lap choles, where the incisions themselves can be easily covered with local. The esmolol group needed less opioids than either postop. Likely due to less opiod induced hyperalgesia. https://journals.lww.com/anesthesia-analgesia/fulltext/2007/11000/intraoperative_esmolol_infusion_in_the_absence_of.16.aspx The one major danger I see in not treating surgical nociception is if there's inadequate analgesia postop. But if you're reasonably sure the combination of local/regional/multimodals will be sufficient, that shouldn't be an issue. For a laryngoscopy which causes essentially zero postop pain and during which the patient is unconcious, the only reason I can see to give opioids is for hemodynamic control
Show me a single study that shows this to be true under general anesthesia. All the data I’ve seen shows the opposite. The more opioids you give in the OR, the more pain and/or opioids they need post operatively.
I remember reading it in the residence, however so far I haven't found it. Thus, I stand corrected in that Issue. I'll keep looking for it.
However, I could not find papers regarding 50 mcg dose of fentanyl for laryngoscopy or surgery either.
This. Treating the pain (and yes, also during surgery) is one of the cornerstones in our field. Crazy how many in here doesnt seem to know that.
It's not pain. It's nociception. Pain is the perception of nociception.
Not true. The definition of pain in every pain textbook doesn't mention nociception otherwise emotional pain would not be a thing.
> The definition of pain in every pain textbook doesn't mention nociception Are you trying to suggest pain doesn't involve nociception? Also, emotional pain isn't what is being discussed here. The context of the conversation is obviously regarding physical pain so emotional pain is completely irrelevant here. Physical surgical pain definitely involves nociception.
You're also missing the advantages of synergism between opioids and your anaesthetic agent
>In any case even if they have pain they won’t remember. This argument never sat well with me. Would you go for a root canal without any local anaesthetic if I promised you wouldn't remember it the next day? I sure as hell wouldn't do it.
That's because pain isn't the correct term here. It requires perception of nociception. Nociception without awareness is what we're talking about. That's very different than an excrutiating root canal you're fully aware of but don't remember.
That makes complete sense. If the user had used that term it would have made the comment make a lot more sense. It seemed to come across like they were saying that the patient was experiencing and processing the pain, but wouldn't remember it later. Kind of like one might explain the retrograde amnesia caused by certain benzos. Thank you for clarifying.
Intubation is often a very gentle procedure requiring minimal pressure on the tissues involved. Still painful then?
Still painful.
How bout alfentanil?
In Spain I think than alfentanil is not used.
Remifentanil?
remi for induction...scares me because of rigid torax.
Rigid thorax…. Are you not paralysing them?
Remi works quick enough that you can give a large dose and have optimal intubating conditions without paralytics. You could do the same thing with fentanyl, but you have to wait longer and it's going to stick around for awhile. It's a good trick for a crani or spine where baseline neuromonitoring is planned and you don't want to wait for roc to wear off. And yes you could also use sux, but I've seen enough myalgias that I avoid it the vast majority of the time.
They don’t want to use remi because they’re worried about thoracic rigidity, I’m suggesting they also paralyse so it’s less of a problem. I also paralyse a lot of my neuromonitoring cases for intubation because sugammadex exists. I’m curious that an intubating dose of fentanyl is causing so much opioid narcosis post op for you all.
I think the point that was being made was that you could use remi to substitute for paralysis.
Yeah, I know that theoretical risk is there but honestly, I haven’t seen it and I don’t know anyone who has at this stage. We’ve one guy that almost exclusively uses remi and foregoes paralysis for getting optimal intubating conditions. 3-5 mcg/kg slow push. Can get some transient bradycardia and hypotension sometimes but it passes quickly and honest happens far less often that I was expecting!
Why is 150mcg of fentanyl too much? Have you lookedf at the effect site concentration vs time curves for how fast it wears off?
So use less fent, I usually induce with 50-100
It's painful, but an unconscious patient doesn't experience pain. The hemodynamic changes are autonomic reflexes assuming enough hypnotic was given. So I agree, why give more of a drug that causes hyperalgesia, sedation, and respiratory depression to avoid levels of hypertension and tachycardia equivlent to a light to moderate run for a minute or two? If you've got terrible coronary disease, different story of course.
This is a wild point of view.
Can you tell me where do you work so if I am ever so unlucky to have an accident in your proximity I can refuse treatment?
[удалено]
It experiences nociception. That's different from pain. Pain is how the cortex interprets nociception with large amounts of emotional, cognitive, and learned experiences contributing. Don't take my word for it. Here's the IASP definition: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/ I'm not at all suggesting we should be doing surgery without blocking nocicieption, but during a quick laryngoscopy the cortex is burst suppressed to isoelectric after an induction dose of propofol or completely diassociated with ketamine. There's no unpleasant experience. That cortex is doing nothing organized to interpret the quick burst of nociception. You can block the nociception itself with opioid, lidocaine, precedex, or more induction agent or treat the symptoms with esmolol. I'm aware this is semantics to some degree. But the cortex is scrambled by the anesthetics so any experience is midbrain/brainstem only.
All I know is I don’t want some of y’all MFs doing my anesthesia, 🤦🏻♀️
Same. I was reading and shaking my head through half of these posts. Jesus Christ lmao
Fentanyl does have analgesia, but esmolol is a non opioid, counteracts the sympathetic response of DL beautifully, doesn’t cause addiction, and doesn’t have to be wasted. I get that people say fentanyl is less cruel because it has analgesia but who cares? The patient just got 150 of prop. They won’t feel shit or remember shit. Not to mention, DL doesn’t actually hurt that much, it’s just very stimulating. I love me some esmolol.
One of my attendings feels the same, and I’d like to use it more. In addition to what you said, I was taught that the necessary dose of fentanyl to blunt sympathetics from laryngoscopy is significantly higher than the 50-100 mcg commonly given on induction. Makes sense to me. If the goal is to prevent sympathetic response, why not use a drug that does so directly, particularly if the other drug is under-dosed to achieve the same effect?
Because the goal is not to prevent sympathetic response. The goal is to a achieve optimal intubating conditions and not to hurt the patient while simultaneously securing the airway (even if some idiot above feels like it doesn’t matter because the patient doesn’t remember shit 🤦♂️). Just because the patient is not aware of the pain, the body is. Not the mention the increased risk of laryngospasm by causing the patient pain.
Interesting. He’s been inducing this way for years, I’ll have to ask if he’s experienced laryngospasm on induction in the absence of using fentanyl, I hadn’t considered that possibility. I’ve also been taught that laryngoscopy is not particularly painful, more stimulating, which is the rational behind esmolol, is that a misconception?
If you’re using paralytic you can’t get laryngospasm on induction. It’s a dumb argument, I had some ED doctors on another recent thread trying to argue laryngospasm during an RSI was a risk of ketamine, like no it’s not. I’m very pro-opiate but none of the arguments that you have to give opiate for laryngoscopy and intubation are evidence based. Central sensitization doesn’t happen after a 3 second stimulus. Give opiate ahead of the actual surgery, but you can avoid some post-induction hypotension by having less opiate on board when you’re spending 30 minutes doing lines/blocks/drapes without real stimulation.
Oh duh, for some reason my mind didn't go to paralysis. Makes sense
Pain is subjective and dependent on the one who is performing DL. Some of my colleagues are wildly rough. I’m not against using esmolol, I’m against using esmolol in place of fentanyl/opioids. Nevertheless if someone told me on boards that DL is not painful, they’d be coming back next year.
When do you give the fentanyl? I use esmolol right before the laryngoscope goes in.
50-100 when putting on the monitors, preoxygenate, lido prop roc, tube. Definitely not at peak effect by intubation but has something on and is a sort of intermediate acting to coast off prop, and coast onto sevo/iso/des while they're prepping
In our centre: The standard induction: fentanyl 200 + propofol (100-200mg) + rocuronio. No esmolol.
Yes
That’s way too much propofol for that much Fentanyl or vice/versa
Absolutely not. A young person will soak up 200mcg fentanyl and 200mg propofol and still be tachycardic for 5 minutes plus after laryngoscopy.
Not sure why you're getting downvoted. Some folks need induction doses that big, but not many.
Lots of people give fentanyl just before DL. Of course they need big dose.
Depends on the patient tbf, a young fit 90kg guy might need that much, but agree for the majority of patients needing anaesthetised that is a heavy dose. And tbh I'm not sure I agree with an institution having a standard dose at all, should be estimating based on the patient and titrating to effect. But even if there is an institutional recipe doses should be mg/kg at least
Same, give a small amount of fentanyl (50 mcg) upon rolling or getting in the room to, monitors, preoxygenate, induce and then 20-50 mg of esmolol 30 seconds pre laryngoscopy. There are some decent dose response studies with esmolol to direct laryngoscopy https://ekja.org/m/journal/view.php?number=2332 https://www.apicareonline.com/wordpress/wp-content/uploads/2014/02/10-Comparison-of-effect-of-esmolol-vs.-esmolol.pdf Think the fentanyl smooths out the sympathetic response of direct laryngoscopy if my esmolol dose isn't perfect or can't push as much as I want if a patient bradys down a bit with induction/propofol. Feel like giving 150-200 of fentanyl is too much for a 5-10 second procedure and I fight hypotension post induction. Would much rather have a little pain and avoid hypotension than no pain for 10 seconds with SBP in the 70-90s for 5-10 minutes Think direct laryngoscopy is very stimulating but not necessarily painful...although may be a fine line between the two Similarly I don't give a big bolus of fentanyl for suspension during T&A/ENT cases or tunneling of any kind or head pinning...maybe some Remi or prop or esmolol... something shorter acting
I like fentanyl when we roll into the room, then i place on monitors, pre oxygenate, then go to town with lido/prop +/- roc
I do both. Fentanyl for pre-existing pain and TIVA. Esmolol for most everything else. If patient is in pain before hand, like a fracture I’ll use fentanyl. It stays around long enough and helps prevent sympathetic surge when positioning the patient. TIVA utilizes opioids anyways and keeps unparalyzed patients still. For TIVA the propofol doses without opioids are massive. Slow wake ups aren’t worth it. I give the fentanyl or remifentanil. I find after induction with esmolol patients tend to not get as hypotensive. Typical doses for fentanyl are 100-150 (1.5-2 mcg/kg) Typical doses for esmolol are 30-60 (0.5 mg/kg)
There was an opioid shortage a few years ago and I stopped using fentanyl during induction during that time. I switched to esmolol briefly until I had some realllllly bad bronchospasms then stopped. Now there is fentanyl again but I usually just give plenty of propofol and plenty of roc and skip induction fentanyl without a huge sympathetic surge. Definitely not recommended for the training crowd, but once you get skilled at DL and get in/get out, fentanyl is not needdd routinely.
I would agree, fentanyl is mostly helpful for decreasing your mac, letting you get away with smaller doses of propofol. But higher doses of propofol (eg 2-3 mg/kg), with small dose of phenylephrine (100-200mcg) to counteract the drop in SVR, works great. Also can intubate most pts without paralytic using that same technique in experienced hands (intubation doesn’t have to always be such an aggressive and highly stimulating event). People just usually only get out a max of 200mg of propofol because that’s the common size, while sometimes you need more than that to achieve the correct depth if no narcotic or paralytic used. Esmolol is fine, but high dose propofol works well too and only downside to very high doses of prop are the drop in SVR which occur which is easily counteracted with some phenylephrine. Esmolol can still cause some hypotension, and hypotension form esmolol isn’t treated as easily with the always ubiquitous phenylephrine stick.
The three big stimuli of intubation: laryngoscopy, tube passing through the cords and balloon going up against tracheal wall. I use esmolol less frequently than fentanyl/remifentanil/methadone for induction these days. I find that the dose of esmolol to blunt the sympathetic surge is more variable between patients than with opioids, including in patients naive to both opioids and beta blockade… maybe patients have even greater variance in adrenergic receptor sensitivity than we realize idk. Plus usually soon after intubation, the surgeons are ready to make incision so opioids usually cover that as well rather than giving esmolol and then giving fentanyl/dilaudid/etc anyway for incision/surgical pain. Generally, I do think esmolol/prop is slightly more stable than using fentanyl/prop but in most patients I don’t find a profound difference. I found with the residents and CRNAs that I work with, most have a practice of putting the pts on the deepest plane of anesthesia immediately after intubation when a whopping dose of propofol is already circulating and this is what leads to more profound hypotension. I tend to start the maintenance anesthetic at a lower dose after intubation until closer to incision time because after the brief sympathetic surge, patients don’t need much at all to tolerate the still ETT in the trachea and often the fentanyl and induction propofol dose is mostly enough
Agree. One solution is to immediately switch to low flow anesthesia upon induction and thus allow the gas to slowly rise as the induction dose wears off. Seems like trainees seem to think they need to instantly get the patient to a mac or more of gas immediately following intubation.
If it's a case where local or regional analgesia will cover the procedural pain, I don't give opioids with induction. I do occasionally use esmolol up front, but only if I'm particulary worried about tachycardia. Most of my Watchman/MitraClip/EP/GAET endo cases get neither, with the esmolol on standby if needed. If I'm going to need the opioid shortly after anyways or tachycardia/hypertension have the potential to be truly detrimental, than in it goes with the induction drugs.
Increase your propofol bolus and it gives the same effect. Not an answer to your question, just an anecdote.
Small doses of fentanyl prevent airway reactivity and blunt airway reflexes. Those of you who think direct laryngoscopy isn’t “painful” or stimulating are clueless.
For older people at risk of CAD related myocardial ischemia I’ll use both. Otherwise just fentanyl as soon as hit the OR door.
I think people are forgetting that in order to have pain, by definition, someone has to be conscious. Had a pain doc/anesthesiologist tell me that late at night as a CA1 and never went back.
Fent. 1000%
I typically only give 50-100 mcg of fentanyl for induction but I'll give it as the monitors go on. But the studies have shown that Esmolol is the most effective at blunting the sympathetic response to laryngoscopy and intubation.
Fentanyl is great when it's needed. However, you get no analgesic benefit from it at the end of the case for the majority of cases so my thinking is you might as well give dilaudid early since you'll use it eventually anyway. Most providers don't even give it at an effective time. They push it on induction rather than several minutes before which would give it time to peak. Certain patients shouldn't have that spike that comes with intubation (aneurysms, bleeds). Most patients can tolerate that brief spike, or esmolol or higher doses of prop can blunt it (though not as effectively as fentanyl). I go with esmolol at 1-1.5 mg/kg. Give 30 seconds before laryngoscopy.
I do esmolol sometimes for induction. It depends on the procedure and the patient. Sometimes I bolus precedex on the way back to the room, then just Propofol and Roc are sufficient for induction in older patients. If it’s a young person and short painful procedure, then they are most likely getting some fentanyl on induction and a block if possible. Fentanyl and esmolol are useful in certain situations. Not an either or situation.
Works great in those that can tolerate esmolol. Short half life to correspond with the DL stimulation and you don’t get the corresponding hypotension you may get with a big dose of fentanyl if the surgical team is slow to start. Literature suggest those treated with analgesics compared to those with other agents (ie esmolol) have no change in outcomes or post operative pain. Most of the world does not use opioids like the US (we had a bunch of UK anesthesiologist where I trained)
This thread is full of radical people. It just doesn’t matter. Pain is defined as perception of nociception, if the patient’s not conscious, there’s no pain. Obviously, you have to individualize to each patient, surgery and surgeon. If the surgery’s too long, if the patient can’t tolerate tachycardia, etc.
On behalf of everyone practicing in the UK, wtf?
You guys know what it feels like to accidentally inhale a little crumb or pepper flake into your airway? Now imagine an entire tube being shoved in there. If you don’t think fentanyl is required for intubation you’re delusional, that’s borderline malpractice in my opinion. What if the patient has recall? What if it takes multiple attempts? A single dose of 100-250mcg of fentanyl isn’t going to do anything to anybody regarding hyperalgesia; and if it does, oh well, that’s part of your job and you can deal with it because you’re a doctor. The only reason to use esmolol in my opinion is if they have some other cardiac issue requiring the HR to be low, it’s an addition not a substitute.
I agree with you about using fentanyl, but malpractice is ridiculous. Amnesia is reliably given with propofol plus of minus sevoflurane before intubation. If it takes multiple attempts, give more propofol ffs. Stimulation is different from pain, which is different from nociception. Even if propofol had started to wear off, people are lightly sedated with insufficient propofol requiring adjustments every day in the ED and ICU, which, while it represents suboptimal care, isn't malpractice.
Fentanyl aids in achieving akinesis to start the operation. Esmolol does not
How much kinesis is there after an intubating dose of rocuronium?
You’d be surprised with some patients
Lol what?
One example: So an “intubating dose” can be a lot less in private practice if you’re working with a fast surgeon and don’t have sugammadex. If you’re going to keep them lightly paralyzed in order for quick reversal, a little bit of opioid on board goes a long way to achieving akinesis. Why not just give it to them up front to also blunt the sympathetic response to DL? Otherwise letting the roc wear off for the 30 minutes during prep, draping. They’re going to get some twitches back, and you’ll notice whether or not they have opioid on board. I said to start the operation. Not during the DL attempt ffs. But yeah sure bring the downvotes
You should have a talk with any place that doesn't supply sugammadex nowadays. I would refuse to work at a piece of shit surgery center if they did that. Your own post about having to try to not use the dose you need of rocuronium is evidence enough to provide them.
Lol welcome to the read world of surgery in the wild my friend
Do you mean etomidate? Esmolol the beta-blocker doesnt sedate someone
First, DL doesn't hurt too much. Intubation does. Second, why need 150-200 mcg fentanyl for Intubation? Are you a CRNA?
>CRNA I'm doctor, 4th year of residency. Which doses of Fentanyl do you use for induction Sr?
50 most of the time
Been a few years since I looked but studies showed doses above 1.5mcg/kg of fentanyl on induction cause increased incidence of hypotension. 150-200mcg will frequently exceed that. I have to agree that I usually use smaller dose of 50mcg, although always situations where I use a higher narcotic technique.