Practical Considerations For The Use Of Sufentanil

The following recommendations for the use of sufentanil in anesthesia, depending on the type and the duration of surgery are given in the next table. If sufentanil is

Table 111-14. Summary of interaction of sufentanil with other agents affecting the cardiovascular system and the possible potentiation and duration of action. None (0), small (+), medium (++), pronounced (+ + +) potentiation and/or duration of action

Agent

Blood pressure

Heart rate

Potentiation of action

Duration of action

Succinylcholine

Increase

Increase

0

0

Vecuronium

0

0

0

0

Curare

decrease

decrease

0

0

Atracurium

decrease

decrease

0

0

Pancuronium

increase

increase

0

0

Barbiturates

decrease

decrease

++

++

Droperidol(> 5mg)

0

0

(+)

0

Benzodiazepines

decrease

decrease

++

+ + +

Propofol

(decrease)

(decrease)

++

++

Volatile agents

0

0

+ + +

N2O

0

0

++

(+)

ß-Blocker

decrease

decrease

++

++

Ca++-Antagonist

decrease

decrease

++

++

«2-Agonist

(decrease)

(decrease)

+ + +

(+)

MAO-Inhibitors

0

0

+

+ + +

Modified from [138, 139, 140, 141]

Modified from [138, 139, 140, 141]

given in combination with a muscle relaxant, however, without nitrous oxide and the patient is ventilated with pure oxygen, induction of anesthesia is started with a loading dose of 0.8-1.0 ^g/kg body weight. For maintenance of anesthesia in case of a reduction of analgesia, a repetitive dose of 0.35-0.7 ^g/kg body weight is suggested. When sufentanil is being used in total intravenous anesthesia (TIVA),

Figure III-47. Hemodynamic measurements in patients undergoing coronary artery by-pass grafting before, and after receiving sufentanil (2 |g/kg). Measurements were done before and after the total dose of sufentanil, after endotracheal intubation, and 5 min after sternotomy. HR = heart rate (beats/min); SAP = systemic artrial pressure (mmHg); CSF = coronary sinus flow (ml/min), GCVF = great coronary vein flow (ml/min). CSF is used as an indicator of global myocardial perfusion, and GCSF denotes left ventricular perfusion (Adapted from [137])

where it is combined with a hypnotic like propofol and the patient is ventilated with 100% oxygen, a loading dose of 1 ^g/kg body weight is advocated. This is followed by a continuous infusion via a motor-driven pump administering a dose of 0.1-0.15 ^g/kg/min. When using this type of anesthesia, it is apparent that the usual dose of the hypnotic can be reduced significantly, because sufentanil by itself already has a pronounced sedative effect. In case of a balanced type of anesthetic technique, where the agent is being used in combination with a volatile anesthetic, initially sufentanil should be administered in a dose of 0.5-0.7 ^g/kg body weight, the first half for intubation and the second half just prior to skin incision. With a maintenance dose of sufentanil of 0.26 ^g/kg, intraoperatively the concentration of the volatile anesthetic can significantly be reduced (i.e., isoflurane 0.3 vol%), in order not to encounter an overhang at the end of the procedure.

It has to be pointed out that with the start of anesthesia, sufentanil should be given in a high enough loading dose. This has several advantages:

• A sufficient high loading dose, given at the start of anesthesia, results in the occupation of all receptor sites, causing a deep level of analgesia with lesser need for additional doses of the opioid.

• Laryngoscopy and intubation by themselves already present a very intense nociceptive stimulus, which can only be blocked sufficiently by a high dose of the opioid.

• The secretion of excitatory transmitters and the subsequent potentiation of nociceptive afferences through "wind-up" can be inhibited before the first burst of nociceptive impulses is being generated.

• Forty five minutes before the end of operation, the patient is in no further need of an additional dose of the opioid. At the end of anesthesia an antagonist will not be necessary and the patient will breathe on his own, showing a sufficient level of wakefulness.

Table 111-15. Recommendations of the appropriate dose of sufentanil for different types of operations using a N2O/O2 based anesthetic regimen. 50%-70% of the titrated dose of sufentanil should be given for induction, the second half just prior to skin incision

Duration operation (h)

Type of operation

Induction dose (|g/kg)

Maintenance dose (|g/70 kg)

1-2

Hysterectomy, cholecyctectomy, osteosynthesis

0.55-1.0

Clinical signs 10-25

2-8

Endarterectomy, colectomy, nephrectomy, gastrectomy

1.0-5.0

Clinical signs 10-25

4-8

AC by-pass, valvular replacement, thoraco-abdominal aneurysm repair (TAA)

4.0-10.0

Before sternotomy 5-10 |g/kg; clinical signs 10-25

• Already during the course of anesthesia the opioid is being metabolized and inactivated. Those amounts of the opioid, which have accumulated in the peripheral compartment, intraoperatively diffuse into the central blood compartment where they do not hide from metabolism via the liver.

• The usual dose of the hypnotic, being necessary for the induction of anesthesia, can be reduced by at least 50%.

• In balanced anesthesia the concentration of the volatile agent can be reduced by 59% because sufentanil has a hypnotic action of its own.

• Sufficient analgesia is maintained throughout the whole procedure and there is no need for re-administration of the opioid in order to sustain a sufficient level of analgesia.

• There is no need for re-administration of the opioid, which otherwise would results in an additional accumulation of the drug in the peripheral compartment, acting like a reservoir (muscles, connecting tissue, fat tissue). From there the drug will flow back into the blood compartment, which may result in a rebound of effects with late respiratory impairment.

In summary it is important to consider the following points when using sufentanil for anesthesia:

1. High loading dose lessens repetitive reinjection, which should be avoided.

2. In TIVA with propofol reduce the amount of the hypnotic

3. In patients with a shock-like state, reduce the usual dose by at least 50% or titrate according to need.

4. In patients with hypovolemia titrate according to need.

5. In patients with marginal myocardial function give a lower dose of the opioid than usual.

6. Combining the opioid with a volatile agent the MAC can be reduced by 50%-60%.

7. In high doses the opioid mediates an antiarrythmic action.

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