Sedation fentanyl

Neuroleptic analgesia is so called because the combination of a major tranquilizer, a neuroleptic dmg, and a potent opiate produces an anesthetic state characterized by sedation, apathy, and mental detachment (see Psychopharmacological agents) (152). Iimovar [8067-59-2] a combination of droperidol [648-72-2], C22H22FN2O2, (19) and fentanyl (9) citrate, is used for procedures that do not require muscle relaxation. However, the onset of action is slow. 

This type of pain management is used for postoperative pain, labor pain, and cancer pain. The most serious adverse reaction associated with the administration of narcotics by the epidural route is respiratory depression. The patient may also experience sedation, confusion, nausea, pruritus, or urinary retention. Fentanyl is increasingly used as an alternative to morphine sulfate because patients experience fewer adverse reactions. 

Users of fentanyl analogues report that these drugs produce a rapid rush or euphoria that is similar to that felt with heroin, followed by a sedated, dream-like state. As analgesics, they also produce a profound loss of pain sensation and have common unwanted side effects such as sleepiness and constipation. However, because they are so potent, fentanyl analogues can... 

Serotonin syndrome SSRIs, second generation antidepressants, MAOIs, linezolid, tramadol, meperidine, fentanyl, ondansetron, sumatriptan, MDMA, LSD, St. John s wort, ginseng Hypertension, hyperreflexia, tremor, clonus, hyperthermia, hyperactive bowel sounds, diarrhea, mydriasis, agitation, coma onset within hours Sedation (benzodiazepines), paralysis, intubation and ventilation consider 5-HT2 block with cyproheptadine or chlorpromazine... 

Fentanyl Slow onset and recovery naloxone reversal available Opioid used in balanced anesthesia and conscious sedation produces marked analgesia... 

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. 

Side-effects The side-effect profile (Poklis, 1995) is typical of potent p-opioids with respiratory depression, increased muscle tone (chest wall rigidity during fentanyl anesthesia), strong sedation and emesis being most prominent. Adverse reactions can be antagonized with naloxone. 

Tranquilizer, sedation, antiemetic Dose Adults. N Initial max 2.5 mg IV/EM, may repeat 1.25 mg based on response Premed 2.5-10 mg IV, 30-60 min preop Peds. Premed 0.1-0.15 mg/kg/dose Caution [C, ] Contra Component sensitivity Disp Inj SE Drowsiness, i BP, occasional tach extrapyramidal Rxns, T QT interval, arrhythmias Interactions T Effects W/ CNS depressants, fentanyl, EtOH T hypotension W/ antihypertensives, nitrates EMS Monitor ECG, may T QT interval epi may cause paradoxical hypotension, do not use fentanyl may cause HTN, do not use if possible use caution w/ analgesics and opioids may T CNS depression monitor for S/Sxs of extrapyramidal Rxns which can be treated w/ Benadryl concurrent EtOH use can T CNS depression OD May cause T of nl SEs symptomatic and supportive... 

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... 

Adjunctive use of potent opioids (eg, fentanyl and related compounds) contributes cardiovascular stability, enhanced sedation, and profound analgesia. Other intravenous agents such as the benzodiazepines (eg, midazolam, diazepam) have slower onset and recovery features and are rarely used for induction of anesthesia. However, preanesthetic administration of benzodiazepines can be used to provide a basal level of sedation and amnesia when used in conjunction with other anesthetic agents. 

During all valvuloplasty interventions antibiotics (e.g., cefuroxime, I, 5 g, i.v.) are administered. Patients allergic to penicillin should receive vancomycin I g intravenously. Most physicians perform transcatheter valvuloplasty in the fasting state under mild sedation, Substances that are frequently used are meperidine, promethazine, and chlorpromazine, given intramuscularly or intermittent doses of midazolam (0.05 to 0.1 mg/kg, i.v.) and/or fentanyl (0.5 to 1.0 Lig/kg, i.v.). Some operators also apply ketamine or general anesthesia for all interventional cases. 

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

Pachulski RT, Adkins DC, Mirza H. Conscious sedation with intermittent midazolam and fentanyl in electrophysiology procedures. J Interv Cardiol 2001 14(2) 143-6. 

Baris S, Karakaya D, Aykent R, Kirdar K, Sagkan O, Tur A. Comparison of midazolam with or without fentanyl for conscious sedation and hemodynamics in coronary angiography. Can J Cardiol 2001 17(3) 277-81. 

Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA, Stanley TH. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990 73(5) 826-30. 

Nausea, vomiting, and pruritus occurred relatively infrequently, with no differences between the groups sedation was more frequent with fentanyl. 

TCAs OPIOIDS 1. Risk of t respiratory depression and sedation 2. t levels of morphine 3. Case reports of seizures when tramadol was co-administered with TCAs 4. TCAs may t codeine, fentanyl, pethidine and tramadol levels 1. Additive effect 2. Uncertain likely t bioavailability of morphine 3. Unknown 4. TCAs inhibit CYP2D6-mediated metabolism of these opioids 1. Warn patients of this effect. Titrate doses carefully 2. Warn patients of this effect. Titrate doses carefully 3. Consider an alternative opioid 4. Watch for excessive narcotization... 

---