The Role of Fentanyl in Balance Anethesia

Muh. Ramli Ahmad

Department of Anesthesiolgy, IC and Pain Management

Faculty of Medicine, Hasanuddin University

Makassar, Indonesia

INTRODUCTION

Goals of surgical anesthesis

1. Loss of pain sensation

2. Loss of consciousness

3. SKM relaxation

4. Autonomic stabilization

General Anesthesia

General Anesthesia

Loss of Consciousness

Analgesia

Reversible Relaxation

INTRODUCTION

Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California, USA, Spinger 2008;191-240

Autonomic

stabilizationTIVA : total intravenous anesthesia

VIMA : Volatile induction Maintanance Anestesia

• Hypnosis (unconsciousness)

• Amnesia

• Analgesia

• Immobility/decreased muscle tone

– (relaxation of skeletal muscle)

• Inhibition of nociceptive reflexes MAC

• Reduction of certain autonomic reflexes

– (gag reflex, tachycardia, vasoconstriction) MAC-BAR ( blockade adrenergic response)

Goals of General Anesthesia

High dosage of Inhalation Anesthetic

Loss of Consciousness -Analgesia

Subcortical / Limbic System

Brain stem depression, Turmoil of Respiration and Hemodynamic ambiance

Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California, USA, Spinger 2008;191-240

Traditional monoanesthesia

Inhalation Anesthetic Loss of consciousness + Analgesia

Fentanyl

Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California, USA, Spinger 2008;191-240

Modern balanced anesthesia

• Furthermore in one study of 150 elective ASA I-III, surgical patients aged 65-92 years old showed that:

– Fentanyl reduced the rises in systolic, diastolic and mean arterial pressures, heart rate, and rate pressure product (P < 0.05)

– Fentanyl decreased the incidence of marked fluctuations in hemodynamic variables, often seen in geriatric patients (P < 0.05).

Opioid in Balanced Anesthesia

Splinter WM, Cervenko F. Haemodynamic responses to laryngoscopy and tracheal intubation in geriatric patients: effects of

fentanyl, lidocaine and thiopentone. CAN J ANAESTH 1989. 3 6; 4:3 7 0 – 6

Traditional monoanesthesia vs. modern

balanced anesthesia

Traditional monoanesthesia modern balanced anesthesia

FARMAKOEKONOMI

• Biaya opersional rumah sangat meningkatterutama kamar operasi

• Data biaya dikeluarkan RS 6% obatanestesi dari seluruh pembelian obat di RS Dari 6% 20% adalah obat inhalasi.

• Mulai dikembangkan Farmakoekonomi

FARMAKOEKONOMI

Farmakoekonomi adalah subdisiplin ilmu ekonomikesehatan yang membandingkan biaya danefektivitas suatu obat terhadap obat lain sertamelakukan analisis keduanya

Analisa ini untuk memberikan pelayanan kesehatanberdasarkan nilai yaitu mendapatkan hasil yang terbaik dengan biaya yang murah

Telah berkembang dinegara maju seperti Amerikaserikat, Jerman dan Australia

• Rapid induction

• Analgesia

• Inhibition of nociceptive reflexes

• Farmakoekonomi / cost effective

• Decrease the MAC

• Reduction of certain autonomic reflexes

– (gag reflex, tachycardia, vasoconstriction)

The Role of Fentanyl in Balance Anesthesia

The Potentiation of Anesthetic Agents with Fentanyl

Fentanyl

• Penggunaan paling sering dari fentanyl adalah sebagai agenanalgesik selama pemberian balanced anesthesia. Dosisfentanyl sebesar 0.5 – 2.5 mcg/kg dilakukan secara intermitendisesuaikan dengan intensitas pembedahan dan dapat diulangkurang lebih setiap 30 menit.

• Dosis alternatif, pemberian loading dose 5-10 mcg/kg daninfus kontinu fentanyl pada kecepatan antara 2-10 mcg/kg/jam dapat direkomendasikan.

Fentanyl

• Onset kerja fentanyl singkat, namun peak effect tercapai dalam waktu 5 menit.

• Pada praktek klinis secara umum, dosis fentanylyang digunakan sebelum dimulai induksi adalah1,5 sampai 5 mcg/kg.

• Titrasi fentanyl dilakukan sekitar 3 menit sebelumdilakukan laringoskopi karena efek puncaknyayang mengalami perlambatan sekitar 3-5 menituntuk mendapatkan efek yang maksimal.

Fentanyl Pharmacokinetics

• Intramuscular

Onset 7-15 minutes

Peak 15 minutes

Duration 1-2 hours

• Intravenous

Onset minutes

Peak minutes

Duration 30-60 minutes

Adverse Reactions:

MS: Muscle rigidity, particularly involving muscles of respiration.

CV: Bradydysrhythmias (common) or tachydysrhythmias, hypotension, orthostatic hypotension

Resp: Respiratory depression (common) or arrest.

CNS: Pupillary constriction. Sedation

GI: Nausea and Vomiting

Derm: Histamine release may cause local or general urticaria

Modern balanced anesthesia

Opioid in medicine, Enno Freye, Joseph Victor levy, University of Pacific, Webster Street, Sanfransisco,California, USA, Spinger 2008

The Potentiation of Anesthetic Agents with Fentanyl

Inhalation Agent Inhalation Agent + Opioid

MAC Reduction of isoflurene by increasing concentrations of fentanyl

A.I. McEwan .Anestesiology 78T. 864-869 tahun 1993

MAC Reduction of isoflurene by increasing concentration of fentanyl

Fentanyl menurunkan MAC agenanestesi inhalasi

(From Katoh T et al: Sevoflurane Requirements for tracheal intubation with and without fentanyl. British Journal of Anesthesia 1999.)

Reduction in MAC, MAC-BAR and MAC Awake of sevoflure by increasing concentration of fentanyl

Takasumi Katoh dkk 199

(From Katoh T, Kobayashi S, Suzuki A, et al: The effect of fentanyl on sevoflurane requirements for somatic and sympathetic responses to surgical incision.

Anesthesiology 90:398-405, 1999.)

Fentanyl menurunkan MAC agen anestesi inhalasi seperti sevoflurane

The Potentiation of Anesthetic Agents with Fentanyl

Katoh and Ikeda, 1999

The Potentiation of Sevoflurane and Fentanyl with Fentanyl Dosage Regiment of 0, 1, 2 and 4 µg/kg BWResult: Fentanyl 4 µg/kgBW was the most effective in decreasing autonomic stimulation along with decreasing Sevofluraneconsumption during operation

Xuan Wang2008

The Potentiation of Enflurane and Fentanyl on Pediatric PatientResult: Fentanyl group showed decreasing EnfluraneMAC level

MAC-BAR : MAC Blockade Adrenal Response

MAC : MAC tracheal intubation

Fentanyl effect on MAP and HR

Fentanyl dosis 4 mcg/kg menurunkan denyut jantung dan MAP lebih efektif dari pada 1 atau 2 mcg/kg

(From Katoh T et al: Sevoflurane Requirements for tracheal intubation with and without fentanyl. British Journal of Anesthesia 1999.)

Fentanyl administration before intubation

• Most effective : 5 minutes before intubation

Ko SH et al. Small Dose Fentanyl Optimal Time of Injection for Blunting the Circulatory

Response to tracheal intubation. Anesth Analg 1998

(dosis pre-intubasi 2 mcg/kg)

Fentanyl administration before intubation

Channaiah et al. Low dose fentanyl : hemodynamic response to endotracheal intubation in

normotensive patients. Arch Med Sci Journal 2008

(dosis pre-intubasi 2 mcg/kg)

Premedication fentanyl added to the propofol regimen was shown able to reduce Systolic Blood Pressure (SBP) response due to airway manipulation (dosis pre-induksi 2 mcg/kg)

Fentanyl administration before intubation

*P <0.05

Adachi A, et al. Fentanyl Attenuates the

Hemodynamic Response to Endotracheal Intubation

More Than the Response to Laryngoscopy. Anesth

Analg 2002;95:233–7

• Premedication fentanyl also affected Diastolic Blood Pressure (DBP) response due to airway manipulation (dosis pre-induksi 2 mcg/kg)

Fentanyl administration before intubation

*P <0.05

Adachi A, et al. Fentanyl Attenuates the

Hemodynamic Response to Endotracheal Intubation

More Than the Response to Laryngoscopy. Anesth

Analg 2002;95:233–7

THE COMPARISION OF 4 µG/KgBW and 2 µG/KgBW FENTANYL to

HEMODYNAMIC STABILITY along with ISOFLURANE CONSUMPTION in LAPAROTOMY GYNECOLOGIC SURGERY

ABDUL MUTTALI . MUH.RAMLI AHMAD

Patient

2µg/kg BW FentanylGroup (N=14)

4µg/kg BW FentanylGroup (N=14)

Laparotomy Gynecology Procedure

Fit The Inclusion criteria

Intubation + Surgery

Response

IsofluraneConsumption

Premedication midazolam 0,05 mg/kgBW

Induction propofol 2-2,5 mg/kg BWAtracurium 0,5 mg/kgBW Maintenace

Monitoring HR,TD,BIS,TOF ETCO2,

(+) Isoflurane 0,5 %

Metode

Hemodynamic Fluctuation (+)

Rescue Fentanyl(--) Isoflurane 0,5%

Grafik perbandingan tekanan darah sistolik antara kedua kelompok

0

20

40

60

80

100

120

140

160

Sblmind

Sdhind

Sdhint

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115

Kontrol

Perlakuan

0.9

24P =

0.3

87

0.1

01

0.0

02

0.0

26

0.0

04

0.0

08

0.0

23

0.0

26

0.0

35

0.0

71

0.0

02

0.0

11

0.0

40

0.0

08

0.0

23

0.0

48

0.2

08

0.0

02

0.0

00

0.0

02

0.0

02

0.0

00

0.0

01

0.0

93

0.0

28

teka

nan

dar

ah s

isto

lik (

mm

Hg)

TEKANAN DARAH SISTOLIK

TEKANAN DARAH DIASTOLIK

LAJU JANTUNG

Comparison of Rescue Dose on Both Group

Comparison of Rescue Dose on Both Group

Control Group Experiment Group P

RESCUE DOSE 130.71 ± 45.987 24.64 ± 29.64 0,0000

All data was shown as mean value and tested with Mann Withney U test as significant was pronounced when p value less than 0.05

Comparison of Isoflurane Consumption

KEBUTUHAN ISOFLURAN

KELOMPOK KONTROL

K.PERLAKUAN

Figure 4. Comparison of Isoflurane consumption on both group

GROUP

Isoflurane Consumption Control Experiment p

47.0871 ± 2.43035.8736± .996

0,0000

All data was shown as mean value and tested with Mann Withney U test as significant was pronounced when p value less than 0.05

RESULT

Fentanyl 4 µg/kgBB Vs 2µg/kgBB

Better Hemodynamic Stability

Less Rescue Dose

Less Isoflurane Consumption

Conclusions

• Fentanyl produces a reduction in the minimum alveolar concentarion ( MAC) of isoflurene, sevoluren and desflurance

• Minimum alveolar concentarion (MAC) and Minimum alveolar concentarion blockade adrenergic response (MEC BAR)MAP and heart rate decreased similarly with creasing concentrations of fentanyl in plasma.

• Somatic and symphatetic responses to surgycal incision are clinical end points for assessing depth of anesthesia

• The intraction of fentanyl on the Cp50 of Propofol and Thiopental.

Thank you!FOR YOUR ATTENTION

• Isoflurane consumption was total of isofluranefor the whole operation (ml) and calculated with the following equation :

C:Mean concentration of the anesthetic volatile agent (vol%, T; Duration

of the operation, Flow O2: O2 flow (l/mnt), (Vapour pressure isoflurane : 240 )

Vol : C x Flow O2 x 1/ Vapour pressure x T