Sufentanil Midazolam

Recovery is sufficiently rapid with most intravenous drugs to permit their use for short ambulatory (outpatient) surgical procedures. In the case of propofol, recovery times are similar to those seen with sevoflurane and desflurane. Although most intravenous anesthetics lack antinociceptive (analgesic) properties, their potency is adequate for short superficial surgical procedures when combined with nitrous oxide or local anesthetics, or both. Adjunctive use of potent opioids (eg, fentanyl, sufentanil or remifentanil see Chapter 31) contributes to improved cardiovascular stability, enhanced sedation, and perioperative analgesia. However, opioid compounds also enhance the ventilatory depressant effects of the intravenous agents and increase postoperative emesis. Benzodiazepines (eg, midazolam, diazepam) have a slower onset and slower recovery than the barbiturates or propofol and are rarely used for induction of anesthesia. However, preanesthetic administration of benzodiazepines (eg, midazolam) can be used to provide anxiolysis, sedation, and amnesia when used as part of an inhalational, intravenous, or balanced anesthetic technique. 

A4 Acetaminophen, alfentanil, amiodarone, astemizole, cocaine, cortisol, cyclosporine, dapsone, diazepam, dihydroergotamine, dihydropyridines, diltiazem, ethinyl estradiol, gestodene, indinavir, lidocaine, lovastatin, macrolides, methadone, miconazole, midazolam, mifepristone (RU 486), paclitaxel, progesterone, quinidine, rapamycin, ritonavir, saquinavir, spironolactone, sulfamethoxazole, sufentanil, tacrolimus, tamoxifen, terfenadine, testosterone, tetrahydro-cannabinol, triazolam, troleandomycin, verapamil Barbiturates, carbamazepine, macrolides, glucocorticoids, pioglitazone, phenytoin, rifampin Erythromycin, 613-hydroxy cortisol... 

Several drugs are used intravenously, alone or in combination with other drugs, to achieve an anesthetic state (as components of balanced anesthesia) or to sedate patients in intensive care units who must be mechanically ventilated. These drugs include the following (1) barbiturates (thiopental, methohexital) (2) benzodiazepines (midazolam, diazepam) (3) opioid analgesics (morphine, fentanyl, sufentanil, alfentanil, remifentanil) (4) propofol (5) ketamine and (6) miscellaneous drugs (droperidol, etomidate, dexmedetomidine). Figure 25-2 shows the structures of... 

Clinically important, potentially hazardous interactions with acenocoumarol, alfuzosin, aminophylline, anisindione, anticoagulants, buprenorphine, butorphanol, caffeine, carmustine, dobazam, cocoa, dicumarol, dofetilide, duloxetine, epirubicin, eszopiclone, fentanyl, floxuridine, fluorouracil, galantamine, gliclazide, hydromorphone, itraconazole, ketoconazole, lidocaine, meptazinol, midazolam, mizolastine, modobemide, morphine, narcotic analgesics, oxprenolol, oxycodone, pentazocine, phenytoin, posaconazole, prednisone, propranolol, sufentanil, tolazoline, warfarin, xanthines, zaleplon, zofenopril, zolmitriptan, zolpidem... 

Ferslew, K.E. Hagardom, A.N. McCormick, W.F. Postmortem determination of the biological distribution of sufentanil and midazolam after an acute intoxication. J.Forensic Sci., 1989, 34, 249—257... 

In general the combined use of benzodiazepines with atfentanil or fentanyl is synei istic but may also result in additive effects on respiratory depression and/or hypotension. A pharmacokinetic study found that fentanyl reduced the metabolism of midazolam. Retrospective evidence suggests that midazolam can increase the dose requirement of sufentanil, but midazolam did not alter the analgesic efficacy of fentanyl in healthy subjects. 

Acute hypotension occurred in a man receiving clonidine, captopril and furosemide who was premedicated with intramuscular midazolam 5 mg and anaesthetised with sufentanil 150 micrograms.This is consistent with another report of sudden hypotension during anaesthetic induction in 4 patients given high-dose sufentanil who had heen given lorazepam before induction. ... 

Uneertain. The additional use of other CNS depressants may produee additive respiratory depressant and sedative effeets. Redueed metabolism of midazolam might also enhanee its effeets. Why midazolam appeared to inerease the analgesie dose requirement for sufentanil is unknown. An in vitro study found that fentanyl eompetitively inhibited the metabolism of midazolam by the eytoehrome P450 isoenzyme CYP3A4. ... 

What effect the use of midazolam has on the dose requirement of sufentanil and other opioids in the intensive care setting is unclear, although it would seem that hypotension is a risk. 

West JM, Estrada S, Heerdt M. Sudden hypotension associated with midazolam and sufentanil. Anesth Analg (1987) 66, 693-4. 

Combination studies The combination of intranasal midazolam 0.53 mg/kg and intranasal sufentanil 1 microgram/kg resulted in over-sedation in a 3-year-old girl, which responded to a combination of flumazenil and naloxone [ISO ]. 

Opioid analgesic drugs (OADs), particularly fentanyl and its analogs alfentanil, remifentanil, and sufentanil, are extensively used for anesthesia and analgesia. Administration of intravenous hypnotics and OADs as a high dose opioid, low dose hypnotic (usually a benzodiazepine such as midazolam) has found wide application in cardiac anesthesia and to produce procedural sedation for endoscopy, catheterizations, and a variety of other surgical procedures where sedation and... 

Noninterfering alfentanil, aprotinin, atropine, bupivacaine, chlorpromazine, dalteparin, dexamethasone, diazepam, dopamine, droperidol, etomidate, fentanyl, furosemide, gallamine, haloperidol, midazolam, morphine, neostigmine, nitroglycerin, nitroprusside, oxytocin, pancuronium, pentobarbital, phenylephrine, phenytoin, pipecuronium, piperacillin, promethazine, propofol, ranitidine, succinylcholine, sufentanil, terbutaline, thiopental, vecuronium, verapamil... 

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