Propofol and fentanyl

Unlike isoflurane, desflurane may stimulate the sympathetic nervous system at concentrations above 1 MAC. Sudden and unexpected increases in arterial blood pressure and heart rate have been reported in some patients, accompanied by increases in plasma catecholamine and vasopressin concentrations and increased plasma renin activity. These pressor effects may increase morbidity or mortality in susceptible patients. The mechanism of sympathetic activation is unclear but does not appear to be baroreceptor-mediated. Clonidine, esmolol, fentanyl and propofol partially block the response but lignocaine (lignocaine) is ineffective. 

All patients are ventilated and sedated (for sedation use fentanyl and propofol). 

A 44-year-old woman developed atropine-resistant but isoprenaline-sensitive bradycardia (36 beats/minute), thought to be due to sinus node dysfunction related to lithium, fentanyl, and propofol (120). 

Sinus bradycardia (36/minute) developed in a 44-year-old woman taking lithium who received fentanyl and propofol (120). 

Acute heart failure has been attributed to fentanyl and propofol [36" ]. 

Fentanyl (no details) Breathing difficulties, wheezing, frothy secretions LTT SPT Positive for fentanyl and proposol Positive for meperidine Anaphylaxis to fentanyl and propofol Diagnosis not firmly established. Could be anaphylactoid. No positive skin test for fentanyl. Relevance of LTT and meperidine SPT Cone, of meperidine SPT ... 

L. E. Merlo, B. A. Goldberger, D. Kolodner, K. Fitzgerald and M. S. Gold, Fentanyl and propofol exposure in the operating room sensitization hypothesis and further data, J. Addict. Dis., 2008, 27, 67-76. 

A relatively large number of studies have investigated the effects of opioids on tests requiring focused attention. Morphine (2.5 to 10 mg, IV)185 and propofol (70 mg, IV)193 impaired an auditory simple reaction time test, and fentanyl (1 to 2.5 ng/ml, IV)182 impaired a visual choice reaction time test. Jenkins et al.197 reported that IV (3 to 20 mg) and smoked (2.6 to 10.5 mg) heroin impaired performance on a simple visual reaction time task. However, other studies reported no effect of butorphanol (0.5 to 2.0 mg, IV),186 fentanyl (25 to 100 pg, IV),191 meperidine (0.25 to 1.0 mg, IV),192 and nalbuphine (2.5 to 10 mg, IV)189 on an auditory simple reaction time test. It may be... 

A 61-year-old woman undergoing mitral valve surgery received fentanyl, midazolam, nitrous oxide, and propofol infusion 3 mg/kg/hour during a 5-hour anesthetic. She developed lactic acidosis soon after the completion of surgery and required reintubation and ventilation. The peak lactate concentration, which occurred 1 day later, was 14.3 mmol/1. There was also mild disturbance of liver function. She eventually recovered. 

In 113 patients undergoing general anesthesia, intravenous midazolam 15 mg slowed recovery of the twitch height after vecuronium and atracurium compared with diazepam. The recovery index was not altered (162). However, in another study in 20 patients, midazolam 0.3 mg/kg did not affect the duration of blockade, recovery time, intensity of fasciculations, or adequacy of relaxation for tracheal intubation produced by suxamethonium 1 mg/kg, nor the duration of blockade and adequacy of relaxation for tracheal intubation produced by pancuronium 0.025 mg/kg in incremental doses until 99% depression of muscle-twitch tension was obtained (161). Furthermore, in 60 patients undergoing maintenance anesthesia randomly assigned to one of six regimens (etomidate, fentanyl, midazolam, propofol, thiopental plus nitrous oxide, or isoflurane plus nitrous oxide), midazolam did not alter rocuronium dosage requirements (165). 

Olkkola KT, Tammisto T. Quantifying the interaction of rocuronium (Org 9426) with etomidate, fentanyl, midazolam, propofol, thiopental, and isoflurane using closed-loop... 

The effects of giving calcium chloride 10 mg/kg after induction of anesthesia with propofol, fentanyl, and pancuronium have been investigated in 58 patients undergoing elective coronary artery bjq)ass grafting (16). Calcium chloride reduced the fall in arterial blood pressure and prevented the reductions in heart rate, stroke volume index, cardiac index, and cardiac output, compared with placebo. Propofol reduces the availabihty of calcium to the myocardial cells, and calcium chloride effectively minimizes the hemodynamic effects of... 

Propofol in subhypnotic doses is a potent antiemetic. In a double-blind, randomized study, a small dose of propofol (0.5 mg/kg) was compared with droperidol (20 micro-grams/kg) or metoclopramide (0.2 mg/kg) given at the completion of surgery performed in 90 patients under standard anesthesia with thiopental, fentanyl, and sevo-flurane (59). Follow-up was to 24 hours. The incidence of emesis at 24 hours was significantly lower in those who received propofol (10 versus 33% and 40% for droperidol and metoclopramide respectively). 

Thiopental, midazolam, propofol, fentanyl, and ketamine are intravenous anesthetics that are discussed. 

Rich JB, Yaster M, Brandt J Anterograde and retrograde memory in children anesthetized with propofol. J Clin Exp Neuropsychol 21 535-546, 1999 Schneider U, Bevalacqua C, Jacobs R, et al Effects of fentanyl and low doses of alcohol on neuropsychological performance in healthy subjects. Neuropsychobiology 39 38-43, 1999... 

Bradycardia and asystole occurred in another patient given propofol, fentanyl and atracurium. The authors of one report suggest that atropine or glycopyrrolate pretreatment should attenuate or prevent such reactions."... 

A 19-year-old girl was given intravenous fentanyl 100 micrograms, midazolam 2 mg, and propofol 150 mg at induction followed by... 

In a randomized blind comparison, patients undergoing sedation for emergency procedures received either ketamine 0.3 mg/kg or fentanyl 1.5 micrograms/kg followed by intravenous propofol 0.4 mg/ kg bolus [62 ]. All five severe events were in those who received fentanyl and fentanyl caused more mild (OR = 5.9), moderate (OR = 3.8), and severe (OR = 12.3) adverse events. Desaturation was the main contributor to this difference. Fentanyl was 5.1 times more likely to cause sedation than ketamine, and this persisted after adjustment for age, weight, procedure type, and pre-procedure pain (OR = 4.6). 

Fentanyl enhances vagal tone and can cause bradycardia. In 27 children undergoing catheter ablation under propofol anesthesia, which has minimal effect on the sinus node, electrophysiological stimulation was performed before and after a bolus dose of fentanyl 2 micrograms/kg and a subsequent infusion of 0.075 micrograms/kg/minute [64 ]. There was an increase in calculated sinus node recovery time but no change in sinoatrial conduction time after fentanyl, suggesting that fentanyl -I- propofol impairs sinus node recovery and therefore... 

A 50-year-old man with no previous history of seizures was anesthetized with fentanyl 100 micrograms and propofol 100 mg. Within 30 seconds of receiving the propofol, he developed tonic-clonic seizures over the trunk and lower body. Despite thiopental 125 mg the seizures recurred and required further boluses of thiopental and midazolam. Surgery continued uneventfully and postoperative recovery was unremarkable. A CT scan of the brain was normal. 

Hollman GA, Schultz MM, Eickhoff JC, Christenson DK. Propofol-fentanyl versus propofol alone for lumbar puncture sedation in children with acute hematologic malignancies propofol dosing and adverse events. Pediatr Crit Care Med 2008 9(6) 616-22. 

Opioids play an important role in anesthetic practice. Opioid analgesics potentiate the efficacy of anesthetics. They can be given as part of the premedication as well as during the operation. Examples of short acting agents with high potency are fentanyl, sufentanyl, alfentanil and remifentanil. Because of their hemodynamic stability these agents can be used for patients with compromised myocardial function. Respiration must be maintained artificially and may be depressed into the postoperative period. They are usually supplemented with inhalation anesthetic, benzodiazepines or propofol. 

A 77-year-old man is admitted to the hospital for a coronary artery bypass. He has been treated with a (3-blocker (Tenormin 100 mg per day), which he took every morning. He is induced with propofol 1 mg/kg, fentanyl 5 jjig/kg and vecuronium 8 mg for muscle relaxation. After 3 minutes a decreasing heart rate becomes a worry for the anesthesiologist. The heart rate continues to fall until it reaches 38 BPM. At this point the patient s blood pressure is 80/60 and the anesthesiologist gives atropine 0.4 mg and ephedrine 10 mg. This treatment results in a stable patient. What effects were most likely produced by the anesthesia procedure Could this have been avoided ... 

Answer This feature of bradycardia is typical of patients who take (3-blockers, which should be continued so they result ultimately in better anesthetic management. The drugs given could have been modified (i.e., etomidate instead of propofol, which does not raise or may cause a slower heart rate). The potent opioids in the fentanyl family all cause vagal transmitted bradycardia. The muscle relaxant vecuronium (norcuron) has no effect on heart rate and could have been replaced by pancuronium, which has a vagolytic effect and will counter bradycardia in the usual induction bolus doses. 

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